What over-the-counter (OTC) medications are recommended for an adult with tension or migraine headaches, considering potential interactions with stomach ulcers, bleeding disorders, or impaired renal (kidney) function?

Over-the-Counter Headache Medications for Adults

For tension-type headaches, ibuprofen 400 mg or aspirin 1000 mg are first-line OTC options, while for migraines, ibuprofen 400 mg or the combination of aspirin 1000 mg + acetaminophen 1000 mg + caffeine 65 mg provides the strongest evidence for efficacy. 1, 2

First-Line OTC Options by Headache Type

For Tension-Type Headaches

• Ibuprofen 400 mg is highly effective for short-term treatment, providing significant pain improvement at 2 hours 3, 4
• Aspirin 1000 mg demonstrates superior efficacy compared to 500 mg doses, with a 75.7% response rate versus 54.5% with placebo 5
• Aspirin 500 mg is less effective than 1000 mg but still superior to placebo (70.3% response rate) 5
• Acetaminophen (paracetamol) 1000 mg is effective but shows lower efficacy than NSAIDs for tension headaches 6, 5

For Migraine Headaches

• Ibuprofen 400 mg is the most effective single-agent OTC option, providing 2-hour headache relief in 57% of patients versus 25% with placebo (NNT 3.2) 1, 2, 4
• Combination therapy: aspirin 1000 mg + acetaminophen 1000 mg + caffeine 65 mg has the strongest evidence for moderate to severe migraines 1, 2
• Ibuprofen 200 mg is less effective than 400 mg (52% versus 57% for 2-hour relief) and should not be the preferred dose 4
• Acetaminophen 1000 mg alone has no evidence for migraine efficacy and should not be used as monotherapy 1

Critical Dosing and Timing Principles

• Take medication early when pain is still mild to maximize effectiveness 2, 7
• Soluble formulations of ibuprofen 400 mg provide faster 1-hour relief compared to standard tablets 4
• Limit use to no more than 2 days per week to prevent medication-overuse headache, which can lead to daily headaches 2
• Do not exceed 10 days of use per month for any OTC analgesic 2

Special Populations Requiring Caution

Patients with Stomach Ulcers or GI Bleeding History

• Avoid all NSAIDs (ibuprofen, aspirin, naproxen) as they increase risk of bleeding, ulcers, and GI perforation 8, 9
• Risk increases with history of stomach ulcers or GI bleeding, longer NSAID use, higher doses, smoking, alcohol use, and age >60 years 8
• Use acetaminophen 1000 mg instead as the only safe OTC option for this population 6

Patients with Bleeding Disorders or Taking Anticoagulants

• Avoid aspirin and NSAIDs due to increased bleeding risk when combined with blood thinners 8, 9
• Aspirin specifically may cause bleeding in the brain, stomach, and intestines 9
• Acetaminophen 1000 mg is the safest alternative 6

Patients with Impaired Renal Function

• Avoid all NSAIDs as they can cause kidney problems including kidney failure 8
• NSAIDs should be avoided in patients with existing kidney problems 8
• Acetaminophen 1000 mg is the preferred option, though monitor total daily intake to not exceed 4000 mg from all sources 2

Patients with Cardiovascular Disease

• Avoid NSAIDs after recent heart attack unless specifically directed by a physician, as they increase risk of another heart attack 8
• Do not use NSAIDs right before or after heart bypass surgery 8
• NSAIDs can cause new or worse high blood pressure and heart failure 8

When to Seek Professional Help

• If headaches occur more than 2 times per week, preventive therapy should be evaluated rather than relying on acute OTC treatment 1, 2
• If OTC medications are needed more than 10 days per month, professional evaluation is required 2
• If using OTC NSAIDs for more than 10 days continuously, consult a healthcare provider 8

Common Pitfalls to Avoid

• Do not use acetaminophen alone for migraine - it lacks evidence for efficacy as monotherapy 1
• Do not use lower doses thinking they are safer - ibuprofen 200 mg and aspirin 500 mg are significantly less effective than higher doses 4, 5
• Do not continue increasing frequency of use when medications stop working - this creates medication-overuse headache 2
• Do not combine multiple NSAIDs or take with corticosteroids, SSRIs, or SNRIs without medical supervision due to increased bleeding risk 8