What to Know About Butalbital-Acetaminophen-Caffeine for Migraine

BAC contains three compounds. Each has a different action to help manage pain:

• Butalbital: This compound is a type of barbiturate. It reduces anxiety and causes drowsiness by relaxing your muscles and nervous system. As it can be habit-forming, medications with butalbital are tightly regulated.
• Acetaminophen: This is a widely used medication to reduce pain and fevers. It’s the generic form of Tylenol.
• Caffeine: Caffeine causes the other two ingredients to work better. It also has some anti-inflammatory effects.

Some BAC medications contain additional active ingredients. For example, Fioricet is also available with codeine, an opioid pain reliever.

Is BAC a controlled substance?

As of August 2022, BAC is on the Drug Enforcement Agency (DEA)’s list of exempted prescription drugs. That means it’s not federally regulated even though it contains butalbital, a regulated substance. Some states still choose to classify BAC as a controlled substance.

In April 2022, the DEA proposed removing the exemption. No decision has been made yet.

BAC is FDA-approved to treat tension headaches. The FDA has not approved its use to treat migraine, but some doctors prescribe it for that purpose.

When doctors prescribe a drug for something other than its approved use, it’s called off-label use.

Some people do find it works for migraine. Still, there’s not a lot of evidence to support its use.

A 2015 review by the American Headache Society analyzed 15 years of research into different migraine treatments. The study grouped treatments into three levels, based on the amount of evidence to support each treatment’s use. Medications that contained butalbital, like BAC, were at the lowest level.

The study concluded that there was not enough clinical evidence to support the use of drugs like BAC to treat migraine. The authors recommended that doctors choose first from the wealth of options with stronger evidence.

The American Academy of Neurology suggests that medications like BAC be used only as a last resort. Most research suggests that, for most people, the risks outweigh the benefits.

As with any medication, there are risks and side effects of BAC.

Some of the most common side effects are:

• drowsiness
• abdominal pain
• nausea or vomiting
• lightheadedness
• feelings of intoxication

Along with side effects, there are other possible risks of BAC.

Acetaminophen overdose

BAC contains acetaminophen. At high doses (3,000 mg per day), acetaminophen can cause liver damage.

Many other over-the-counter or prescription medications also contain acetaminophen. It’s important to be aware of your total daily intake of acetaminophen.

Medication-overuse headache

Butalbital also carries a higher risk of medication-overuse headaches. This risk is highest if you take BAC for 10 or more days per month.

Dependence and withdrawal

Butalbital is part of the barbiturate family. This group of medications has the potential to create dependence.

Withdrawal symptoms can occur after stopping BAC. This is more likely to happen if you’ve been using BAC for a long time or are developing dependency.

Symptoms of withdrawal may include:

• tremors
• disorientation
• delusions
• insomnia
• hallucinations

It’s important to seek medical attention if you have any of those symptoms after stopping BAC.

There is not enough research to know if BAC is safe during pregnancy. For this reason, experts recommend that you avoid BAC during pregnancy.

According to 2021 research, barbiturates like butalbital pose several risks to pregnant people. It may suppress your immune system. There’s also a higher risk of developmental issues for the fetus.

Experts generally consider acetaminophen safe during pregnancy. Still, they recommend low doses. Recent research suggests that it could affect development in the womb.

Research suggests that up to 200 mg per day of caffeine is safe during pregnancy.

If you’re pregnant or may become pregnant, talk with your doctor about other options.

BAC can interact with other medications. Before taking BAC, it’s important to review your medications with your doctor or pharmacist. Make sure to mention both prescription and nonprescription medications and supplements.

The following types of medication are known to interact with BAC:

• monoamine oxidase (MAO) inhibitors
• general anesthetics
• opioids (also known as narcotics) such as fentanyl, oxycodone, codeine, or methadone
• medications used to treat insomnia

There’s a risk of acetaminophen overdose with BAC and any medications containing acetaminophen. Too much acetaminophen can damage your liver.

Acetaminophen overdose

Each dose of BAC contains 300 to 325 mg of acetaminophen. Many other medications also contain acetaminophen. Your upper daily limit from all sources is 3,000 mg per day.

Acetaminophen is the active ingredient in Tylenol. Other common brands containing the compound include:

• Actamin
• Cepacol
• DayQuil
• Excedrin
• Feverall
• Midol
• NyQuil
• Panadol
• Percocet
• Robitussin

This isn’t a complete list. Double-check your medications to ensure that you’re taking a safe amount. If unsure, talk with a doctor or pharmacist.

A variety of medications are available to prevent or treat migraine. It can take time to figure out the right types and doses. If you are going through this process, be sure to follow up with a doctor often.

Here are some medications used to treat migraine:

Anti-inflammatories

Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce inflammation and often relieve pain. They’re often very effective and have few side effects. You can usually get these over the counter.

Examples include:

• ibuprofen (Advil, Motrin)
• aspirin
• naproxen (Aleve)

Triptans

Triptans are prescription medications that help to calm nerves that become overactive during a migraine attack. They also shrink enlarged blood vessels in your brain that occur during migraine.

There are currently seven triptans approved for migraine treatment by the FDA. They are:

• sumatriptan
• eletriptan
• naratriptan
• zolmitriptan
• rizatriptan
• frovatriptan
• almotriptan

Antiemetics

Antiemetics help treat nausea and vomiting associated with migraine. These medications include metoclopramide and prochlorperazine.

The above treatments can help you if you have a migraine attack. But some other medications may help you prevent migraine attacks.

Beta-blockers

Beta-blockers slow down your heart rate by blocking certain hormones. It’s unclear exactly how they work to prevent migraine. Examples include:

• propranolol
• timolol
• bisoprolol
• metoprolol
• atenolol
• nadolol

Antiepileptics

Research shows that some antiepileptics may help prevent migraine. But it’s not fully understood how they do this. Topiramate and valproate are the medications with the most evidence for migraine prevention.

Antidepressants

Some antidepressants may also help prevent migraine. Experts are not sure why they prevent migraine. It may have to do with their effect on serotonin in your brain.

The most common antidepressants doctors prescribe to treat migraine are amitriptyline and fluoxetine.

Butalbital-acetaminophen-caffeine (BAC) is a combination medication, with each of its three components working a little differently to manage pain. Doctors prescribe it to treat tension headaches. But a doctor may also prescribe it off-label to treat migraine.

Experts think BAC should be a last resort for migraine treatment. There’s little evidence to support its benefits, and it has some serious risks. They include intoxication, dependence, and withdrawal, among others.

There are several other treatments for migraine with fewer risks. Talk with a doctor to understand your options. Together, you can arrive at a decision that is best for you.