What outpatient pain medication can be prescribed for a patient with a headache who is allergic to codeine (opioid analgesic)?

Outpatient Pain Medication for Headache in Patient with Codeine Allergy

For a patient with headache who is allergic to codeine, I recommend using a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen as first-line treatment. 1

First-Line Treatment Options

• NSAIDs are recommended as first-line therapy for headache pain, with evidence showing they are more effective than codeine-acetaminophen combinations and have a safer side effect profile 1
• Specific NSAID options include:
  • Ibuprofen 400-600 mg every 6 hours (maximum 2400 mg daily) 1
  • Naproxen 500 mg initially, then 250 mg every 6-8 hours (maximum 1250 mg daily) 1
  • Aspirin 500-1000 mg every 4-6 hours (maximum 4000 mg daily) 1
• Acetaminophen 1000 mg every 6 hours (maximum 4000 mg daily) is an alternative if NSAIDs are contraindicated 1

For Moderate to Severe Headache (If Migraine)

• If the headache is moderate to severe and has migraine features, add a triptan to the NSAID or acetaminophen 1
• Sumatriptan 50 mg orally is effective for moderate to severe migraine with pain relief occurring within 2 hours in 50-61% of patients 2
• The combination of a triptan with an NSAID shows greater efficacy than either medication alone 1

Treatment Algorithm

1. Initial treatment: Start with an NSAID (ibuprofen, naproxen, or aspirin) at appropriate dosage 1
2. If inadequate response: Ensure the patient is using an adequate dose of the NSAID before considering alternative treatments 1
3. For migraine features: Add a triptan (sumatriptan 50 mg) to the NSAID regimen 1
4. For severe nausea/vomiting: Consider a non-oral triptan formulation (nasal spray, injection) with an antiemetic 1, 3

Important Considerations

• Avoid opioids (including those without codeine) for headache treatment due to risk of medication overuse headache, dependency, and reduced efficacy over time 1, 3
• Butalbital-containing medications should also be avoided for headache treatment 1
• For patients who don't respond to NSAIDs and triptans, CGRP antagonists (gepants) such as rimegepant or ubrogepant may be considered 3
• Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 3

Special Situations

• If the patient has contraindications to NSAIDs (such as renal impairment, gastric ulcers, or bleeding disorders), acetaminophen should be used as the primary analgesic 1, 4
• For pregnant patients with headache, acetaminophen is the safest first-line option 4
• For patients with severe migraine not responding to other treatments, dihydroergotamine may be considered if there are no cardiovascular contraindications 3

By following this approach, you can provide effective pain relief for a patient with headache who has a codeine allergy while minimizing the risk of adverse effects and medication overuse.