Are Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) or acetaminophen (Tylenol) more effective for treating headaches?

NSAIDs vs. Tylenol for Headache Treatment

NSAIDs are more effective than acetaminophen (Tylenol) for treating headaches, particularly for mild to moderate migraine attacks, and should be considered first-line treatment for most headache types. 1

Comparative Efficacy for Different Headache Types

Migraine Headaches

• For mild migraine attacks:

  • NSAIDs (aspirin, ibuprofen, naproxen) are recommended as first-line treatment 1
  • Acetaminophen is also effective but generally less so than NSAIDs 1, 2
  • Aspirin-acetaminophen-caffeine combination is strongly recommended if available 1

• For moderate to severe migraine:

  • Start with an NSAID (ibuprofen 400-800mg or naproxen sodium) 1
  • If inadequate response, add a triptan to the NSAID 1

Specific NSAID Recommendations

• Ibuprofen 400-800mg is specifically recommended as first-line acute treatment for migraine (strong recommendation) 1
• Naproxen sodium is also recommended as first-line treatment 1
• In children, ibuprofen was shown to be twice as likely as acetaminophen to abort migraine within 2 hours 3

Efficacy Data

• NSAIDs have demonstrated superior efficacy compared to acetaminophen in multiple studies:

  • Ibuprofen provides better pain relief than acetaminophen for migraine 3
  • NSAIDs are more effective at reducing associated symptoms like photophobia and phonophobia 1

• Acetaminophen efficacy data:

  • Acetaminophen 1000mg is statistically superior to placebo but has an NNT (number needed to treat) of 12 for pain-free response at two hours, which is inferior to other commonly used analgesics 4
  • In one study, acetaminophen 1000mg showed a 52% response rate (reduction from moderate/severe to mild/no pain) compared to 32% for placebo 5

Safety Considerations and Contraindications

NSAID Cautions

• Use NSAIDs with caution in patients with:
  • Gastrointestinal disease
  • Renal disease
  • Cardiovascular disease 1
• Risk of medication overuse headache with NSAIDs if used ≥15 days/month for ≥3 months 1

Acetaminophen Considerations

• Generally well-tolerated with adverse event rates similar to placebo 4
• May be a useful first choice for patients with contraindications to NSAIDs or aspirin 4
• Less effective than NSAIDs but has a better safety profile for certain patients

Treatment Algorithm

1. For most headache types, especially migraine:

   • First-line: NSAID (ibuprofen 400-800mg or naproxen sodium)
   • Alternative first-line for those with NSAID contraindications: Acetaminophen 1000mg

2. For inadequate response to initial treatment:

   • Add a triptan to the NSAID or acetaminophen
   • Consider combination therapy (aspirin-acetaminophen-caffeine)

3. For patients with severe nausea/vomiting:

   • Consider adding an antiemetic to either NSAID or acetaminophen
   • Acetaminophen 1000mg plus metoclopramide 10mg has shown efficacy comparable to sumatriptan 100mg 4

Common Pitfalls to Avoid

• Overuse of either medication class can lead to medication overuse headache
• Underdosing NSAIDs (full anti-inflammatory doses are needed)
• Not considering patient-specific contraindications when selecting therapy
• Delaying treatment (early intervention improves efficacy) 1
• Using opioids or butalbital-containing medications, which are not recommended for headache treatment 1, 2

In summary, while both medication classes are effective, NSAIDs generally provide superior headache relief compared to acetaminophen and should be the first choice when not contraindicated.