What is the recommended dosage and treatment plan for an adult patient with a history of migraines using Naproxen (nonsteroidal anti-inflammatory drug)?

Naproxen 500 mg Twice Daily for Migraine

Naproxen 500 mg twice daily is an appropriate first-line treatment regimen for mild to moderate migraine attacks, but must be strictly limited to no more than 2 days per week to prevent medication-overuse headache. 1, 2

Recommended Dosing Strategy

Initial dose: 500-825 mg naproxen sodium at migraine onset, ideally when pain is still mild 2, 3

Subsequent dosing: Can be repeated every 12 hours (500 mg) or every 6-8 hours (250 mg) as needed 3

Maximum daily dose:

• First day: 1250 mg maximum 3
• Subsequent days: 1000 mg maximum 3

Critical frequency limitation: Restrict use to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 2

Clinical Efficacy Evidence

• Naproxen achieves pain-free response at 2 hours in only 17% of patients (NNT = 11), compared to 8% with placebo 4
• Headache relief at 2 hours occurs in 45% of patients (NNT = 6.0), compared to 29% with placebo 4
• This modest efficacy means naproxen alone is effective in fewer than 2 in 10 patients for complete pain relief 4

When to Escalate Treatment

If naproxen fails after 2-3 migraine episodes, escalate to combination therapy: 2

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg is superior to either agent alone, with 65% achieving 2-hour headache response versus 49% with sumatriptan alone or 46% with naproxen alone 5, 6
• This combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours 2
• The combination reduces headache recurrence to 29% versus 41% with sumatriptan alone 5

Adjunctive Antiemetic Therapy

Add metoclopramide 10 mg or prochlorperazine 25 mg taken 20-30 minutes before naproxen to provide synergistic analgesia and improve outcomes compared to naproxen alone 2

• Antiemetics provide direct analgesic effects through central dopamine receptor antagonism, independent of their antiemetic properties 2
• This is appropriate even when vomiting is not present, as nausea itself is one of the most disabling migraine symptoms 2

Contraindications and Precautions

Do not use naproxen in patients with: 2

• Renal impairment (creatinine clearance <30 mL/min) 2, 3
• Aspirin/NSAID-induced asthma 2
• Active GI bleeding 2
• Moderate to severe renal impairment 3

Use lower doses in: 3

• Elderly patients (increased unbound plasma fraction) 3
• Patients with hepatic impairment 3

When to Initiate Preventive Therapy

Preventive therapy is indicated when: 1, 2

• Two or more migraine attacks per month producing disability for 3+ days 1
• Using acute medications more than twice weekly 1, 2
• Contraindication to or failure of acute treatments 1

Common Pitfalls to Avoid

Do not allow patients to increase frequency of naproxen use in response to treatment failure - this creates a vicious cycle of medication-overuse headache. Instead, transition to combination therapy (triptan + NSAID) or initiate preventive therapy 2

Do not continue naproxen monotherapy if it fails to provide adequate relief after 2-3 attacks - escalate to combination therapy rather than increasing dose or frequency 2

Do not use naproxen for more than 3 consecutive days per attack, even if limiting to twice weekly overall 2