Headache Management in Dengue Fever: Paracetamol Remains the Only Safe Option
For dengue-associated headache, paracetamol (acetaminophen) is the only recommended analgesic—NSAIDs and aspirin are contraindicated due to bleeding risk, and no alternative pain medications have established safety in this population. 1, 2
Why NSAIDs Are Absolutely Contraindicated
NSAIDs significantly increase bleeding risk in dengue patients due to platelet dysfunction and the hemorrhagic potential of dengue hemorrhagic fever (DHF), making them dangerous even in classic dengue fever 1, 2
The WHO dengue guidelines explicitly recommend against NSAIDs, and real-world data from Japan showed that 12.9% of dengue fever patients and 18.8% of DHF patients inappropriately received NSAIDs, potentially increasing adverse events 2
While one recent 2025 study suggested low-dose ibuprofen (cumulative 0.6g during hospitalization) showed similar safety to acetaminophen in non-severe dengue patients, this represents a single retrospective study with very low cumulative doses that contradicts established guidelines 3
The Evidence Hierarchy Strongly Favors Paracetamol Alone
Paracetamol is the only antipyretic specifically recommended by WHO dengue management guidelines for fever and pain control in dengue patients 1, 2
Among Japanese dengue patients, 57.8% of those under 20 years and 54.5% of those 20 years or older appropriately received acetaminophen, demonstrating it as the standard of care 2
The headache in dengue fever is characteristically intense, bilateral, throbbing, frontal, and retro-orbital—and is actually more intense in classic dengue fever than in the more severe DHF 4
Critical Management Algorithm
Use paracetamol as the sole analgesic at standard dosing (1000mg every 6 hours, maximum 4000mg/24 hours) for headache and fever control 1, 2
Monitor for warning signs of DHF/DSS including thrombocytopenia, hemoconcentration (rising hematocrit), hemorrhagic manifestations, and plasma leakage (pleural effusion, ascites) 1
Provide supportive care including adequate hydration with isotonic fluids (not hypotonic fluids which were inappropriately used in 24.5% of DF and 48.4% of DHF patients in Japan) 2
Avoid platelet transfusion prophylactically—guidelines show no evidence of efficacy, yet 17.2% of DHF patients in Japan inappropriately received platelet transfusion 2
Common Pitfall to Avoid
Never use aspirin or traditional NSAIDs (ibuprofen, naproxen, diclofenac) for dengue-associated headache, as the antiplatelet effects and bleeding risk far outweigh any analgesic benefit 1, 2
The single 2025 study suggesting ibuprofen safety used extremely low cumulative doses (0.6g total during hospitalization) in carefully selected non-severe cases—this does not justify routine NSAID use and contradicts established WHO guidelines 3
If paracetamol provides inadequate pain relief, escalate supportive care and monitoring rather than adding NSAIDs—the headache typically resolves as the acute febrile phase subsides 1, 4