Is it safe to prescribe oral steroids (e.g. prednisone) and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (e.g. ibuprofen) together for 5 days to an adult patient with cervicogenic headache caused by cervical spondylosis and no significant medical history?

Can You Give Oral Steroids and NSAIDs Together for 5 Days?

Yes, you can safely prescribe oral steroids (prednisone) and NSAIDs (ibuprofen) together for 5 days in an adult patient with cervicogenic headache from cervical spondylosis, but this combination increases gastrointestinal bleeding risk and requires careful patient selection and monitoring.

Evidence for Combined Use in Rheumatologic Conditions

The combination of corticosteroids and NSAIDs is commonly used in clinical practice, particularly in rheumatologic conditions:

• In Adult Onset Still's Disease (AOSD), 88% of patients required prednisone in addition to NSAIDs at some point, with 46% requiring maintenance treatment with both medications 1
• The combination is used when NSAID monotherapy proves insufficient, which occurs in 85-93% of AOSD patients 1

Specific Application to Cervicogenic Headache

For cervicogenic headache caused by cervical spondylosis:

• NSAIDs are recommended as first-line therapy for cervicogenic headache, though evidence for their effectiveness is limited 2, 3
• Corticosteroid injections (epidural or facet joint) have been used for cervicogenic headache, though evidence remains controversial 4
• No oral medication has proven definitively effective for cervicogenic headache specifically 3
• Surgical decompression has shown success in severe cases of lower cervical spondylosis causing cervicogenic headache 5

Critical Safety Considerations and Risk Mitigation

The FDA warns that NSAIDs carry increased risk of bleeding, ulcers, and gastrointestinal perforation, with risk factors including:

• Taking corticosteroids concurrently 6
• Longer duration of NSAID use 6
• Higher NSAID doses 6
• Advanced age (>60 years) 1
• History of peptic ulcer disease 1
• Alcohol use (≥2 drinks daily) 1

To minimize risk with this 5-day regimen:

• Use the lowest effective NSAID dose (ibuprofen 400-600 mg every 6-8 hours rather than maximum doses) 1, 6
• Limit duration strictly to 5 days as planned 1, 6
• Consider adding a proton pump inhibitor (omeprazole 20-40 mg daily) for gastroprotection, especially if the patient has any GI risk factors 1
• Avoid this combination entirely if the patient has active GI bleeding, severe renal impairment (CrCl <30 mL/min), or history of NSAID-induced ulcers 1, 6

Monitoring Requirements

For short-term use (5 days), extensive monitoring is not required, but counsel the patient to:

• Stop NSAIDs immediately if they develop black/tarry stools, vomit blood, severe stomach pain, or signs of GI bleeding 6
• Take both medications with food to reduce gastric irritation 7, 6
• Avoid alcohol during treatment 6

Alternative Approaches to Consider

Given the limited evidence for oral medications in cervicogenic headache:

• Physical therapy and manual therapy may be more appropriate first-line interventions 3
• Greater occipital nerve blocks or cervical facet joint injections have limited but more direct evidence for cervicogenic headache than oral medications 3, 4
• If oral therapy is preferred, consider NSAIDs alone first before adding corticosteroids 2, 3

Practical Prescribing Algorithm

For a 5-day course in an adult with no GI risk factors:

• Prednisone 20-40 mg daily in the morning (before 9 AM) 7
• Ibuprofen 400-600 mg every 6-8 hours with food (maximum 2400 mg/day) 6
• Omeprazole 20 mg daily for gastroprotection 1
• Strict 5-day limit on both medications 1, 6

Contraindications requiring alternative approach:

• Active or recent GI bleeding 6
• Severe renal impairment (CrCl <30 mL/min) 1
• History of NSAID-induced ulcers 1
• Uncontrolled hypertension or heart failure 1