Can I give etoricoxib (COX-2 inhibitor) or paracetamol (acetaminophen) plus tramadol (opioid) to a patient experiencing migraine symptoms?

Can You Give Etoricoxib or Paracetamol Plus Tramadol for Migraine?

You should NOT use etoricoxib or paracetamol plus tramadol as first-line treatment for migraine—instead, use standard NSAIDs (ibuprofen, naproxen) or paracetamol alone for mild-moderate attacks, and reserve triptans for moderate-severe attacks. 1

Why Etoricoxib Is Not Recommended

• Etoricoxib (a COX-2 inhibitor) is not mentioned in any major migraine treatment guidelines and lacks the robust evidence base that standard NSAIDs possess for acute migraine treatment 1
• The American College of Physicians specifically recommends aspirin, ibuprofen, and naproxen sodium as first-line NSAIDs with strong evidence for migraine efficacy 1
• Standard NSAIDs like ibuprofen (400-800 mg) or naproxen sodium (500-825 mg) have established efficacy with NNTs of approximately 5-6 for headache relief at 2 hours 1, 2

Why Tramadol Should Be Avoided

• Opioids (including tramadol) should be reserved only for when other medications cannot be used, when sedation is not a concern, or when abuse risk has been addressed 1
• The American Academy of Family Physicians explicitly recommends avoiding medications containing opiates as they lead to dependency, rebound headaches, and eventual loss of efficacy, particularly in chronic daily headaches 1
• Tramadol falls into the "rescue medication" category that should only be considered for severe attacks not responding to first-line treatments 1

Paracetamol Alone: A Reasonable But Suboptimal Option

• Paracetamol 1000 mg alone is statistically superior to placebo but has an NNT of 12 for 2-hour pain-free response, which is inferior to other commonly used analgesics 3
• Paracetamol may be useful as a first choice for patients with contraindications to NSAIDs or aspirin 3
• The combination of paracetamol 1000 mg plus metoclopramide 10 mg provides efficacy equivalent to oral sumatriptan 100 mg, making it a more effective option than paracetamol alone 3

Recommended Treatment Algorithm Instead

For Mild-to-Moderate Attacks:

• Start with standard NSAIDs: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg 1, 2
• Alternative: paracetamol 1000 mg if NSAIDs are contraindicated 3
• Add an antiemetic (metoclopramide 10 mg or prochlorperazine 25 mg) 20-30 minutes before the analgesic for synergistic benefit 1

For Moderate-to-Severe Attacks:

• Use triptans (sumatriptan 50-100 mg, rizatriptan, or others) as first-line therapy 1
• Combination therapy of triptan plus NSAID is superior to either agent alone 1, 2

Critical Frequency Limitation:

• Limit all acute medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache 1, 4
• If requiring acute treatment more frequently, initiate preventive therapy immediately 1

Special Consideration: Pregnancy

If your patient is pregnant or of childbearing potential:

• Paracetamol 1000 mg is the first-line medication during pregnancy 5
• Tramadol and other opioids should be avoided due to risks of dependency, rebound headaches, and potential fetal harm 5
• NSAIDs can only be used in the second trimester, not first or third 5
• Metoclopramide is safe for migraine-associated nausea during pregnancy 5

Common Pitfalls to Avoid

• Do not establish patterns of frequent opioid use (including tramadol), as this creates medication-overuse headache and dependency 1, 4
• Do not use etoricoxib when evidence-based NSAIDs with proven migraine efficacy are available 1
• Do not use paracetamol plus tramadol as routine therapy—this combination lacks guideline support and carries opioid-related risks 1, 4
• Monitor total daily paracetamol intake to ensure it doesn't exceed 4000 mg/day from all sources 1