Butalbital, Aspirin, Caffeine, and Codeine (Oral)

As a combination of painkillers, barbiturates and stimulants, butalbital, aspirin, caffeine and codeine capsules are an effective treatment for tension/muscle contraction headaches.

Overview

Butalbital, aspirin, caffeine and codeine are combined and marketed under the names Ascomp and Fiorinal as a treatment for tension headaches, which are caused by muscle contractions within the head and neck areas. These headaches are often caused or exacerbated by activities and stressors, such as staring at a computer screen for prolonged periods or driving for a long time. Each of the ingredients in Ascomp/Fiorinal functions to alleviate a different set of symptoms associated with tension headaches only the combination of butalbital, aspirin, caffeine and codeine should not be used for treating headaches that come and go (migraine).

Butalbital is an instant-acting barbiturate which is often combined with other medications to treat various types of pain. It is not typically suggested as a first-line treatment for headaches because of its propensity to impair alertness, create a dependency or addiction within the patient and even increase the risk that episodic headaches develop further and become chronic. However, when other treatments do no function effectively or are otherwise available Butalbital is considered an appropriate choice.

Aspirin is a widely-used medication which is often prescribed to treat fever, pain or inflammation. Its use has been documented for at least 2,400 years, and it is regarded by the World Health Organisation as an essential medicine. It is widely recognized as effective in the treatment of tension headaches, and is one of the most affordable painkillers in the world. A typical monthly dose of aspirin costs less than $25.

Caffeine is a stimulant of the central nervous system, and is the world's most popular psychoactive substance. It functions by blocking the action of adenosine on its receptor, and this consequently prevents drowsiness. Caffeine also stimulates certain parts of the autonomous nervous system. When combined with butalbital it helps to counteract the impairment of alertness and lack of co-ordination induced by the barbiturate.

Codeine is a naturally-occurring opiate used to treat various types of pain. It is a reasonably fast-acting compound, typically getting to work within half an hour of ingestion. Its effects last for approximately six hours, making it useful for the treatment of long-term pain such as headaches or muscular problems. Codeine is broken down by the liver and converted into morphine, and is the world's most commonly taken opiate. It is currently included on the list of essential medicines by the World Health Organization (WHO).

When combined, these medicines form an effective all-in-one treatment against tension headaches, helping to relieve a dull, aching pain in the head, a sensation of pressure or tightness in the forehead or sides/back of the head, and tenderness in the shoulder, neck and scalp muscles.

Conditions treated

  • Tension headache

Type of medicine

  • Painkiller

Side effects

Along with the desired effects, the combination medication of butalbital, aspirin, caffeine and codeine can cause some unwanted effects. Each of these medicines can cause unique side effects, and patients are therefore advised to discuss the use of this combined medicine prior to using it. In some instances, a doctor may prescribe a more suitable medicine if the patient is likely to react adversely to one of more ingredients in this combination medicine.

The most common side effects reported by patients undergoing treatment with butalbital include: drowsiness, dizziness, light-headedness, sedation, a feeling of intoxication, confusion, excitement (mania), depression, vomiting, abdominal pain, nausea and/or dyspnea.

The most common side effects reported by patients using aspirin include: black or tarry stools, abdominal pain, bloody or cloudy urine, confusion, constipation, appetite loss, muscle tremors, nervousness, nausea, vomiting, rapid breathing, restlessness, diarrhea, skin rash, fever, a general feeling of weakness or tiredness, heartburn, stomach cramps, weight gain, yellowing of the eyes and skin, unusual bruising or bleeding, seizures, numbness and/or tingling feeling in the extremities.

Other side effects experienced rarely (albeit often enough to warrant mentioning) by patients undergoing treatment with aspirin including excessive belching, dry mouth, hyperventilation, shaking, irritability, difficulty sleeping and a feeling of sluggishness.

The most common side effects associated with caffeine use include: agitation, chills, confusion, a feeling of burning or tenderness in the stomach, lethargy, irritability, stomach upset, trouble breathing, hostility, indigestion, shaking, black or tarry stools, bruising, and/or muscle twitching.

Patients who experience irritability, nervousness, rapid heartbeat or difficulty sleeping may be experiencing the effects of caffeine overdose. Although caffeine overdose is not serious when the drug is taken recreationally in coffee or other hot drinks, exceptionally large doses of medicinal caffeine can be fatal. Patients are therefore advised to take great caution when taking any medicine that contains caffeine.

The most commonly experienced side effects reported by patients undergoing treatment with codeine include: blurred vision, bloating, cold or clammy skin, constipation, dark urine, dizziness, labored breathing, dizziness (especially when suddenly getting up from a prone position), loss of appetite, light-headedness, nausea, low blood pressure, redness in face and arms, excess sweating, vomiting or yellow eyes or skin.

Other symptoms which have been reported rarely (albeit often enough to warrant mentioning) by codeine users include: an unusual sense of wellbeing, seeing halos around lights, disturbed perception of color, blurry or reduced vision, dry mouth, hive or welts, itching of the skin, night-blindness, tunnel vision, weight loss and/or difficulty sleeping.

Patients who experience any of the following symptoms while taking codeine should seek medical assistance immediately, as these are all signs that the patient may have overdosed: chest pain or discomfort, bluish skin or lips, small or constricted pinpoint-like pupils, decreased responsiveness or awareness, extreme drowsiness or sleepiness, slow or irregular heartbeat and/or severe sleepiness.

Typically, most patients will only experience very minimal side effects when undergoing treatment with a combination of butalbital, aspirin, caffeine and codeine. As the patient continues to take this medicine, the aforementioned side effects should lessen over time. If any side effects in particular get worse over time or persist for a prolonged period, the patient is advised to raise this with their doctor as soon as possible. With regard to minor side effects, doctors, pharmacists and healthcare professionals may be able to offer advice on how to alleviate symptoms using natural means or over the counter medicines. For example, an incidence of dry mouth may be relieved by sucking on sugar-free candy, chewing sugar-free gum, sucking on ice cubes or drinking regular glasses of ice cold water.

Because a combination of butalbital, aspirin, caffeine and codeine can potentially affect the psychology of the patient, he or she should be prepared to experience mood swings, confusion, memory issues, hallucinations, depression and/or mania. With this in mind, healthcare professionals and caregivers should prescribe this medication with caution to patients with a history of mental health problems. In some instances, a doctor may choose to only prescribe small amounts of the medication at a time to decrease the potential for intentional overdose.

Because some of the side effects caused by this combination medication include drowsiness, lack of co-ordination, dizziness and a feeling of drunkenness or inebriation, patients are advised against driving or operating heavy machinery until it has been ascertained how this medicine affects their judgement and ability to concentrate. In most instances, doctors will advise against driving when using this medication in order to protect the patient and other road users from the potential for serious injury as a result of losing control due to intoxication.

Dosage

As with all medicines, it is important to take a combination treatment of butalbital, aspirin, caffeine and codeine only as prescribed by a doctor or qualified healthcare professional. This means that patients should refrain from taking any more of this medication than they have been advised to, both in terms of dose size and frequency. In addition to this, patients who are advised by their doctor to stop taking a combination of butalbital, aspirin, caffeine and codeine should do so immediately even if they still possess a remaining supply of the medication.

A combination treatment of butalbital, aspirin, caffeine and codeine is typically administered orally, in capsule form. The dosage of this medicine will differ from patient to patient dependent on personal physiology and pain threshold. The amount of this medicine a patient should take will also depend on the strength of the prescribed medicine. The manufacturer recommends that patients should take 1 to 2 capsules as needed every 4 hours, and should not exceed more than 6 capsules per day however, it should be reiterated that these recommendations can be altered by the patient's doctor on a case-by-case basis. A doctor may also adjust dosage during treatment to a higher or lower level based on the response of the patient.

Patients should take butalbital, aspirin, caffeine and codeine capsules with a full glass of water (8 ounces/240ml) unless directed to do otherwise by a doctor. After taking the medicine, patients are advised not to lie down for at least ten minutes afterwards. Patients who experience nausea when taking this medication are advised to take it with food to reduce some of the stomach conditions it can cause. Those who experience extreme nausea should consult with their doctor or healthcare provider to find out about ways to decrease nausea, which can include lying down for an hour with little or no head movement at least 10 minutes after taking the drug, as well as taking antihistamines or other medicines designed to combat allergies and symptoms of sickness.

Because this drug has a high rate of physical dependence among patients, its extended use is not recommended. It should only be used as prescribed, for the relief of complex tension or muscle contraction headaches, and its use should be ceased before it becomes habit-forming. This is because patients who become dependent on combination butalbital, aspirin, caffeine and codeine capsules could potentially experience withdrawal symptoms. These symptoms can include watery eyes, a runny nose, changes in mood and/or seizures, which are more likely to occur if the patient suddenly stops using the medication. To prevent any potentially serious or harmful withdrawal reactions, patient and doctor should work together to reduce dosage of the drug gradually.

In order to avoid incidences of abnormal drug-seeking behavior or addiction, the patient should stick to the prescribed dose and avoid increasing it, either in frequency or dose size.

Patients are advised not to take double doses. In the event of the patient missing a dose, he or she can take the missed dose, provided it is not close to the time of day for the next dose to be administered. If the patient considers it to be closer to the time for the next due dose, they should omit the missed dose and simply continue taking the next planned dose as normal.

Interactions

All drugs have the potential to react with chemicals or other medicines within the human body. These interactions can potentially change the way in which one or more of the involved medications work. In some instances, interactions can render a medicine ineffective. In others, interactions can cause potentially dangerous side effects. Because of this, it is important for patients to keep a full and detailed list of all medications they are currently taking, including the dosage and frequency of each drug. This applies to vitamins, complimentary medicines, herbal supplements and over the counter remedies as well as prescribed medications.

Below is a list of drugs known to interact negatively with butalbital. Patients who are currently taking any of the following drugs should inform their doctor prior to taking butalbital, either on its own or as a combination medication with aspirin, caffeine and codeine:

  • Ibuprofen
  • Guaifenesin
  • Hydrocodone
  • Phenylephrine
  • Morphine
  • Brinzolamide
  • Butorphanol
  • Dalteparin
  • Dasatinib
  • Dazidox
  • Methadone
  • Fentanyl
  • Dicumarol
  • Enoxaparin
  • Eliquis
  • Farydak
  • Fondaparinux
  • Hemin
  • Imbruvica
  • Jadenu
  • Ketorolac
  • Larapam
  • Tramadol
  • Leflunomide
  • Lonvenox
  • Meperidine
  • Oxycodone
  • Oxyfast
  • Omacetaxine
  • Orgaran
  • Panobinostat
  • Ponatinib
  • Ramucirumab
  • Ranozaline
  • Rapamune
  • Regorafenib
  • Roxanol
  • Remifentanil
  • Rivaroxaban
  • Stadol
  • Sodium biphosphate
  • Sprix
  • Tacrolimus
  • Tinzaparin
  • Tizanidine
  • Tositumomab
  • Tylenol
  • Warfarin
  • Zanaflex
  • Zubsolv

Below is a list of medications known to interact with caffeine. Patients undergoing treatment with any of the following medicines should inform their doctor prior to undergoing treatment with caffeine, either as a standalone medication or in combination with butalbital, aspirin and codeine:

  • Tizanidine
  • Zanaflex
  • Alosetron
  • Ciprofloxacin
  • Deferasirox
  • Enoxacin
  • Ephedrine
  • Phenobarbital
  • Grepafloxacin
  • Hydroxyprogesterone
  • Hylutin
  • Fluvoxamine
  • Irenka
  • Jadenu
  • Lithium
  • Makena
  • Norfloxacin
  • Orap
  • Ocaliva
  • Penetrex
  • Potassium iodide
  • Ramelteon
  • Rasagiline
  • Rasuvo
  • Ropinrole
  • Theophylline
  • Uniphyl
  • Vemurafenib
  • Zelboraf

Below is a list of medications known to interact with aspirin. If the patient is currently taking any of these medicines, they should inform their doctor prior to taking aspirin, either as a standalone treatment or as part of a combination capsule alongside butalbital, caffeine and codeine:

  • Acetazolamide
  • Anisindione
  • Apixaban
  • Ardeparin
  • Ibuprofen
  • Betrexaban
  • Brimonidine
  • Cabzantinib
  • Clexane
  • Warfarin
  • Dicumarol
  • Dalteparin
  • Danaparoid
  • Desirudin
  • Edoxaban
  • Farydak
  • Sodium phosphate
  • Genpril
  • Methazolamide
  • Hydrocodone
  • Ibrutinib
  • Iclusig
  • Jadenu
  • Leflunomide
  • Menadol
  • Omacetaxine
  • Ponatinib
  • Regorafenib
  • Rivaroxaban
  • Sirolimus
  • Tacrolimus
  • Teriflunomide
  • Tinzaparin
  • Tipranavir
  • Tositumomab
  • Vicoprofen
  • Zevalin

Below is a list of medications known to interact with codeine. Patients who are currently undergoing treatment with any of these medicines should inform their doctor prior to taking a first dose of codeine, either as a standalone treatment or as part of a combined capsule for tension headaches alongside butalbital, aspirin and caffeine:

  • Abilify
  • Atropine
  • Fentanyl
  • Alprazolam
  • Amobarbital
  • Buprenorphine
  • Bupropion
  • Butorphanol
  • Brexpiprazole
  • Clorazepate
  • Clozapine
  • Carisoprodol
  • Cariprazine
  • Chlorphenesin
  • Cyclobenzaprine
  • Diazepam
  • Dolacet
  • Morphine
  • Droperidol
  • Diastat
  • Ephedrine
  • Ethchlorvynol
  • Fluoxetine
  • Furazolidone
  • Gablofen
  • Halazepam
  • Hydromorphone
  • Hydroxyzine
  • Hydrocodone
  • Iopamidol
  • Iloperidone
  • Kadian
  • Lorazepam
  • Levorphanol
  • Loxapine
  • Lurasidone
  • Orphenadrine
  • Oxazepam
  • Paliperidone
  • Pimozide
  • Pentazocine
  • Procarbazine
  • Propoxyphene
  • Phenelzine
  • Phenobarbital
  • Quetiapine
  • Quazepam
  • Risperidone
  • Secobarbital
  • Subutex
  • Soma
  • Tasimelteon
  • Tranylcypromine
  • Vistazine
  • Vivitrol
  • Wellbutrin
  • Olanzapine
  • Zolpidem

Patients who are currently taking a combination of butalbital, aspirin, caffeine and codeine are advised to avoid alcohol or medications which contain alcohol. Alcohol interacts with many ingredients in this medication and as a result, the patient may experience an increase in side effects which affect the nervous system including dizziness, drowsiness, difficulty concentrating, light-headedness, impaired thinking and impaired judgement. In severe cases, patients who combine alcohol and a combination of butalbital, aspirin, caffeine and codeine may also experience low blood pressure (hypotension), fainting, respiratory failure, coma or even death. This is because alcohol can facilitate rapid release of certain components of this medication, resulting in high blood plasma concentrations of the drug which can potentially be lethal.

Warnings

Patients are advised to contact their doctor if this medicine stops working as well as it did when it was first administered. This can be a sign that the patient is in danger of becoming dependent on this medicine. In the event of this happening, patients should avoid attempting to achieve better pain relief by increasing the dosage. Patients who are having more frequent headaches when using a combination of butalbital, aspirin, caffeine and codeine (for example, experiencing a new headache within a day after last taking a dose of the medicine) may already be dependent on the medicine. As a result, continuing to take the medication will cause further headaches later-on, as and when the medicine wears off.

Patients who currently suffer from one or more of the following conditions should consult with their doctor before taking a combination capsule of butalbital, aspirin, caffeine and codeine - this is because the effects of these conditions could worsen as a result of taking this medicine:

The use of butalbital is contraindicated in patients who are prone to acute alcohol intake. Caution should therefore be taken in patients who suffer from alcoholism when using this medication. When combined with alcohol, this medication can cause severe respiratory depression leading to death. Patients who inadvertently take a dose of this drug while under the influence of alcohol are advised to contact their local poison control center or alternatively visit their local ER.

Aspirin can potentially cause serious allergic reactions, including (but not limited to) anaphylaxis. Left untreated, anaphylaxis has a fast-onset and can be potentially life threatening. Patients who are currently taking a combination of butalbital, aspirin, caffeine and codeine should discontinue use of this medicine immediately if they experience swelling of the face, hands or mouth, or experience difficulty breathing, an outbreak of hives or a rash.

Because this medicine contains caffeine, patients are advised to limit the use of beverages, foods or other medicines which contain caffeine. This means that patients should try to cut down on coffee, tea, dark chocolate and caffeine-containing energy drinks or supplements.

Nursing mothers who are using caffeine, either as part of a combination capsule alongside butalbital, aspirin and codeine or independently, should take care when breastfeeding. If the patient's baby experiences any of the following symptoms, the patient should contact a doctor straight away:

  • If the baby experiences apnea
  • If the baby has a faster heartbeat, restlessness, an increase in diaper wetting, jitteriness or shaking.
  • If the baby has a distended stomach or abdominal area, is vomiting or experiences bloody stools. These may be signs of an abnormal reaction to caffeine, or caffeine overdose.

Codeine is converted to morphine within the body. Some patients may convert codeine to morphine faster than others, and these individuals are known as ┼ôultra-rapid metabolizers┬Ł. Patients who experience confusion, extreme sleepiness, and/or shallow breathing may in fact be ultra-rapid metabolizers of codeine. As a result, the patient can end up with too much morphine within the body.

Nursing mothers who are classed as ultra-rapid metabolizers should take great caution when breastfeeding as the potential for a morphine overdose in the baby is vastly increased, and this can cause serious side effects or potentially be fatal. Mothers who are currently breastfeeding should:

  • Talk to their doctor if they have any questions or concerns about morphine use and how this may affect breastfeeding infants.
  • Contact their doctor immediately if they become incredibly tired and encounter difficulty looking after their baby.
  • Ensure that their baby nurses every 2-3 hours and sleeps for no longer than 4 hours at a time while undergoing treatment with codeine or a combination medication containing codeine.
  • Contact their local emergency room immediately if their baby shows increased signs of sleepiness, difficulty breathing, difficult breastfeeding or limpness. Each of these could be evidence of morphine overdose and may require immediate medical attention.

Storage

Combination capsules containing butalbital, aspirin, caffeine and codeine should be stored at room temperature. Additionally, the manufacturer recommends that this medication is kept away from natural light and moisture it is therefore not suitable for storage in the bathroom, and should ideally be kept in a locked and dedicated storage cabinet, out of the reach of children and pets.

If the patient has been advised to stop taking this medication and has an excess supply, they should take great care to dispose of it safely and hygienically. Combination butalbital, aspirin, caffeine and codeine capsules should not be flushed down the toilet or poured down a drain. Instead, they should be correctly discarded via a local waste disposal company or pharmacy operating a takeback scheme for unwanted medications.

Summary

A combination of butalbital, aspirin, caffeine and codeine (often marketed in the US and Canada as Ascomp or Fiorinal) is an incredibly effective treatment for the alleviation of symptoms associated with tension headaches, such as a constant ache affecting both sides of the head, a tightness in the neck muscles and a feeling of excess pressure behind the eyes. Approximately 2 out of every 100 adults will experience tension headaches multiple times in a month, known as a chronic tension headache.

Combination butalbital, aspirin, caffeine and codeine capsules are an affordable means of treating these headaches, however the propensity for patients to become dependent on this medication means that great caution should be taken both by the prescribing doctor and patient undergoing treatment. Patients with a history of alcohol or drug abuse should inform their doctor prior to taking this medication, and patient and doctor should work together to ascertain the optimum dosage for this medicine.

In some instances, a doctor may recommend a combination of butalbital, aspirin, caffeine and codeine capsules with natural, complimentary and physio-therapeutic techniques to alleviate symptoms of tension headaches, including massage, yoga, exercise, the application of a hot flannel to the forehead/neck area and other relaxation methods to help with stress, which is known to cause these types of headache.

Patients should avoid taking a combination treatment of butalbital, aspirin, caffeine and codeine for prolonged periods of time to avoid risking addiction and to ensure the medication remains effective when it is required.

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Last Reviewed:
December 24, 2017
Last Updated:
April 11, 2018
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