What medication should be prescribed for discharge for a patient with a headache managed with IV paracetamol and no focal neurological deficits?

Headache Management After IV Paracetamol Treatment

For a 42-year-old female patient with a 3-day headache and no focal neurological deficits who received IV paracetamol, an NSAID such as naproxen sodium or ibuprofen should be prescribed for discharge as first-line treatment. 1, 2

First-Line Treatment Options

• NSAIDs are recommended as first-line treatment for mild to moderate headaches due to their demonstrated efficacy and favorable tolerability profile 1, 2
• Specific NSAIDs with strong evidence include:
  • Ibuprofen (400-600 mg every 6-8 hours) 3, 1
  • Naproxen sodium (500-550 mg twice daily) 3, 1
  • Aspirin (500-1000 mg) 3, 1, 4
• Combination medications containing acetaminophen, aspirin, and caffeine are also effective as first-line therapy 3, 1, 2

Why Not Paracetamol (Acetaminophen) Alone?

• Evidence shows that paracetamol (acetaminophen) alone is ineffective for migraine treatment 3, 5
• Paracetamol 1000 mg alone has a high NNT (Number Needed to Treat) of 12 for pain-free response at two hours, which is inferior to other commonly used analgesics 5
• Paracetamol may be useful only for patients who cannot tolerate NSAIDs or aspirin 5

Treatment Algorithm Based on Headache Severity

For Mild to Moderate Headache:

• Start with an NSAID (ibuprofen 400 mg or naproxen sodium 500 mg) 1, 2
• Consider adding caffeine to enhance analgesic efficacy 1
• Avoid using analgesics more than twice weekly to prevent medication-overuse headache 3

For Moderate to Severe Headache:

• Consider adding a triptan to an NSAID if headaches are moderate to severe and don't respond adequately to an NSAID alone 2
• Triptans with good evidence include sumatriptan, naratriptan, rizatriptan, and zolmitriptan 3, 1
• For headaches with nausea or vomiting, add an antiemetic like metoclopramide 3, 1

Important Considerations and Cautions

• Begin treatment as early as possible during an attack to improve efficacy 1
• Limit acute therapy to no more than twice weekly to prevent medication-overuse headache 3
• Medication-overuse headache results from frequent use of acute medications, leading to increasing headache frequency and potentially daily headaches 3, 1
• If the patient has more than two headaches per week, consider preventive therapy 3
• Avoid opioids as they can lead to dependency, rebound headaches, and eventual loss of efficacy 3, 1

Special Circumstances

• If the patient cannot tolerate NSAIDs or has contraindications:
  • Consider combination therapy with acetaminophen plus aspirin plus caffeine 3, 1
  • For patients with nausea and vomiting, consider adding metoclopramide 10 mg 3, 1
• If headaches are severe or recurrent despite NSAID therapy:
  • Consider triptans as an alternative or add-on therapy 1, 2
  • Sumatriptan, naratriptan, rizatriptan, and zolmitriptan all have good evidence for efficacy 3, 1