Ibuprofen as Abortive Migraine Therapy
Yes, ibuprofen is an appropriate abortive therapy for migraine when it works well for a patient, and should be continued as first-line treatment for mild to moderate attacks. 1
Evidence-Based Recommendation
The 2023 VA/DoD Clinical Practice Guideline explicitly recommends ibuprofen for the short-term treatment of migraine (weak for recommendation), placing it among accepted first-line abortive therapies alongside other NSAIDs like aspirin and naproxen. 1 This recommendation is further supported by high-quality research demonstrating that ibuprofen 400 mg provides 2-hour headache relief in 57% of patients versus 25% with placebo (NNT 3.2), and achieves 24-hour sustained relief in 45% versus 19% with placebo (NNT 4.0). 2
Optimal Dosing Strategy
- Use ibuprofen 400 mg rather than 200 mg - the higher dose provides significantly better 2-hour headache relief (57% vs 52%) with similar tolerability. 2
- Administer as early as possible during the attack while pain is still mild to maximize efficacy. 1, 3
- Consider soluble formulations if available, as they provide more rapid 1-hour relief compared to standard tablets, though 2-hour outcomes are equivalent. 2
Critical Frequency Limitation
Strictly limit ibuprofen use to no more than 2 days per week to prevent medication-overuse headache (MOH), which paradoxically increases headache frequency and can lead to daily headaches. 4, 5 If your patient requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than allowing increased frequency of ibuprofen use. 4
When to Escalate Beyond Ibuprofen
While ibuprofen is appropriate when effective, recognize these scenarios requiring treatment escalation:
- Moderate to severe attacks - triptans (sumatriptan, rizatriptan, zolmitriptan) become first-line therapy and are superior to NSAIDs alone for severe attacks. 1, 3
- Combination therapy - for patients with moderate-to-severe migraine, the combination of a triptan plus NSAID (like naproxen) is superior to either agent alone. 4, 5
- Attacks with significant nausea/vomiting - consider non-oral routes (subcutaneous sumatriptan, intranasal zolmitriptan) or add antiemetics like metoclopramide 20-30 minutes before ibuprofen for synergistic benefit. 1, 4
Common Pitfall to Avoid
The most critical error is allowing patients to gradually increase their frequency of ibuprofen use as attacks become more frequent or severe. 6 This creates a vicious cycle where medication overuse perpetuates headaches, making them refractory to treatment. 6 Instead, when ibuprofen is needed more than twice weekly, transition to preventive therapy (propranolol, topiramate, or CGRP monoclonal antibodies) while maintaining appropriate acute treatment limits. 4, 7
Safety Profile
Ibuprofen demonstrates excellent tolerability with adverse events occurring at the same rate as placebo, mostly mild and transient in nature. 2 This favorable safety profile, combined with proven efficacy and guideline support, validates its continued use when effective for an individual patient.