Ask an Expert: Headache Pain Relievers

Q: What pain medicines are safe to use for headaches? With all the recent recalls and new safety warnings, I’m worried that I may be risking a stroke or heart attack every time I take something to get rid of a headache.

Answer from Carl Balog, M.D., medical director of Pain Medicine at Providence Portland Medical Center, and Elizabeth Tindall, M.D., rheumatology and immunology physician at Providence St. Vincent Medical Center and president of the American College of Rheumatology: 

The pain relievers that have drawn recent attention are a large group of over-the-counter and prescription medicines called nonsteroidal anti-inflammatory drugs, or NSAIDs. They decrease pain, inflammation and fever.

NSAIDs started hitting the news in late 2004 after research studies showed an increased risk of "serious cardiovascular events" – mainly heart attack and stroke – in patients who take a newer generation of NSAIDs (cox-2 selective NSAIDs) for an extended time. These studies prompted the Food and Drug Administration to take a closer look at the cardiovascular effects of some of the older, traditional NSAIDs, as well.

In general, the FDA sees little risk in using traditional NSAIDs (whether prescription or non-prescription) to relieve short-term pain, as long as you use them as directed. "Short-term" means pain that lasts less than a week to 10 days, such as headaches, as well as temporary pain from sports injuries, menstrual cramps, muscle strains, dental pain, post-partum pain and post-surgical pain.

For this kind of short-lasting pain, the FDA advises using the lowest possible effective dose for the shortest possible time. (Read the label for dosing info.) The FDA also is requiring manufacturers to rewrite their product information to include warnings about potential cardiovascular and gastrointestinal problems and to emphasize the safe use of the drugs. (Overusing traditional NSAIDs, such as aspirin, ibuprofen and naproxen, can irritate the stomach lining, upset digestion and cause peptic ulcers or bleeding in the digestive tract.)

Treating tension headaches
Some headaches, especially sudden, severe ones, are due to extremely serious medical conditions, such as a stroke, aneurysm or other cerebral bleeding – these require immediate medical attention. Pinched nerves or arthritis in the upper vertebrae also can cause headaches – a chiropractic physician may help relieve some of these kinds of recurring headaches.

But generally, headaches fall into two broad categories: tension and migraine. You seem to be asking about tension headaches. Resolving these involves several steps:

Listen to your body. Most headaches are due to stress and muscle tension. Dehydration, hunger, stale air and fatigue are other causes. Ask yourself what might be causing your headache and if you can do anything to change your environment or the stressful situation. Cold water,* a light meal, fresh air or a rest can help. (*In addition to hydrating you, ice water may have a pain-reducing effect on the blood vessels in your head.

Relax for an hour. This advice is not always practical. But lying down in a dark, quiet room and relaxing is powerful medicine. Relaxation combined with an over-the-counter NSAID should resolve most headaches within an hour. Meditation, yoga, massage and guided relaxation can help a highly stressed person relax. (If your head still hurts after trying this, you may have a migraine, or your headache may be due to a different cause.)

Watch the caffeine. For some people, caffeine helps relieve a headache. For others, it worsens the pain.

Take medicine with a good drink of water. The water won’t increase the effectiveness of NSAIDs, but it will help keep them from damaging your liver and kidneys and will ease their effect on your stomach.

It's smart to pay attention to the circumstances that lead to your headaches, and to the measures that are effective in resolving them.

Deciding which NSAID to take
Is one over-the-counter NSAID superior to the others? Individuals vary in how they respond to drugs. But in the FDA's review of the data on this matter, aspirin and naproxen (Aleve) were the two that showed the least connection with heart attack or stroke.

Prolonged use of NSAIDs for arthritis is more complicated.
For any pain that lasts longer than a week to 10 days, the FDA urges you to talk with your doctor to review the risks and benefits of various medicines, the guidelines for their use, and therapeutic alternatives to drugs. This advice applies to people of all ages who are in good general health, as well as to those with health challenges.

If you suffer from frequent headaches, here's a final word of warning: Beware of over-using pain relievers. Taking the maximum recommended dose of a pain reliever for even a few days in a row can lead to rebound headache, which often presents itself as a headache you wake up with in the morning. This is a sign that your body has developed a physical dependence on the medicine and is protesting its absence. The cure is to gradually wean yourself from it. You might want to ask your physician for guidance in tapering off, because the process can be painful.

June 2005