Norgesic for Headache Treatment
Direct Recommendation
Norgesic (orphenadrine/aspirin/caffeine combination) is not recommended as a first-line treatment for headache, and superior evidence-based alternatives should be used instead. While the aspirin and caffeine components have proven efficacy for acute headache treatment, the addition of orphenadrine (a muscle relaxant) lacks evidence for headache management and adds unnecessary side effects without demonstrated benefit 1.
Evidence-Based Alternative Approach
First-Line Treatment for Mild-to-Moderate Headache
Use the proven triple combination of aspirin + acetaminophen + caffeine instead, which has superior evidence for both migraine and tension-type headache 1, 2:
- Aspirin 250-500 mg + Acetaminophen 200-500 mg + Caffeine 50-65 mg is more efficacious than monotherapy with any single component 2, 3
- This combination works for severe headache as well, with time to 50% pain relief significantly superior to placebo (p = 0.0008) 3
- The caffeine component provides synergistic analgesia by enhancing absorption and efficacy of the analgesics 1, 4
Alternative Single-Agent NSAIDs
If combination therapy is not available, use single-agent NSAIDs as first-line 1, 5:
- Ibuprofen 400-800 mg at headache onset 1
- Naproxen sodium 500-825 mg (can repeat every 2-6 hours, maximum 1.5 g/day) 1
- Aspirin 1000 mg alone 1
Critical Frequency Limitation
Restrict all acute headache medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 4. If headaches occur more frequently than twice weekly, initiate preventive therapy immediately rather than increasing acute medication use 1.
Why Norgesic Is Not Optimal
The orphenadrine component in Norgesic:
- Has no evidence supporting efficacy for headache treatment 1
- Adds anticholinergic side effects (dry mouth, urinary retention, confusion, especially in elderly) without headache benefit
- The aspirin and caffeine components are the only active ingredients for headache, making the orphenadrine unnecessary
When to Escalate Treatment
If NSAIDs or aspirin/acetaminophen/caffeine combinations fail after 2-3 headache episodes 1:
- For moderate-to-severe migraine: Add a triptan (sumatriptan 50-100 mg, rizatriptan, or zolmitriptan) 1
- Combination triptan + NSAID is superior to either alone for moderate-to-severe attacks 1
- Consider adding metoclopramide 10 mg for nausea and additional analgesic benefit 1
Important Contraindications
Avoid aspirin-containing products (including Norgesic) in patients with 1:
- Active GI bleeding or peptic ulcer disease
- Aspirin/NSAID-induced asthma
- Severe renal impairment (CrCl <30 mL/min)
- Uncontrolled hypertension or cardiovascular disease (if considering triptan escalation)