Is it appropriate to give paracetamol (acetaminophen) for generalized non-migrainous headache with an acute history?

Management of Generalized Non-Migrainous Headache

For generalized non-migrainous acute headache, NSAIDs such as ibuprofen (400-600mg) or naproxen sodium (500-550mg) are recommended as first-line treatment rather than the proposed paracetamol tapering regimen. 1

First-Line Treatment Options

The American Academy of Family Physicians recommends NSAIDs as the first-line treatment for most primary headaches, including:

• Ibuprofen 400-600mg
• Naproxen sodium 500-550mg
• Aspirin
• Acetaminophen-aspirin-caffeine combination

These medications should be taken early in the headache phase for maximum effectiveness 1.

Paracetamol (Acetaminophen) Use

While paracetamol can be effective for headaches, it is generally considered less effective than NSAIDs for primary headaches:

• Paracetamol 1000mg has been shown to be statistically superior to placebo for acute headache treatment, but with a relatively high NNT (Number Needed to Treat) of 12 for pain-free response at two hours 2
• It may be a useful alternative for patients who have contraindications to or cannot tolerate NSAIDs or aspirin 2
• The proposed tapering regimen (500mg TDS for 5 days, then BD for 5 days, then OD for 5 days, then as needed) is not supported by evidence in the guidelines

Medication Overuse Considerations

An important concern with the proposed regimen is the risk of medication overuse headache:

• The American Academy of Family Physicians recommends limiting use of acute headache medications to no more than twice weekly to prevent medication overuse headache 1
• Over-the-counter medications should be limited to no more than 14 days per month 1
• The proposed 15-day scheduled regimen could potentially lead to medication overuse headache

Alternative Approaches

For patients with frequent headaches, consider:

• Non-pharmacological approaches: regular aerobic exercise, maintaining regular sleep schedule, adequate hydration, identification and avoidance of triggers, and relaxation techniques 1
• If headaches occur ≥2 times per month with significant disability, preventive treatment may be warranted 1

Recommendation Summary

1. Use NSAIDs as first-line treatment for non-migrainous acute headache
2. Consider paracetamol 1000mg as an alternative only if NSAIDs are contraindicated
3. Limit acute medication use to prevent medication overuse headache
4. The proposed tapering regimen of paracetamol is not recommended and could potentially lead to medication overuse headache
5. Address underlying causes and consider non-pharmacological approaches

Caution

Medication overuse is a common pitfall in headache management. The proposed 15-day scheduled regimen of paracetamol could potentially lead to medication overuse headache, which can be difficult to treat. Instead, limit acute medication use and focus on identifying and addressing underlying causes of headache.