What is the preferred treatment between ibuprofen and diclofenac for a general headache in an adult patient with no severe underlying medical conditions?

Diclofenac vs Ibuprofen for General Headache

For general headache in adults, both diclofenac and ibuprofen are equally effective first-line options, but diclofenac may offer faster onset of pain relief and better tolerability. 1, 2

Evidence-Based Recommendation

Both NSAIDs Are Guideline-Recommended First-Line Agents

• The American College of Physicians identifies both ibuprofen and diclofenac as effective first-line NSAIDs for acute headache treatment, with no clear superiority between them for moderate to severe migraine. 1
• The Nature Reviews Neurology guidelines specifically list acetylsalicylic acid, ibuprofen, and diclofenac potassium as first-line medications with the strongest evidence for acute migraine treatment. 1

Diclofenac May Have Slight Advantages

• Diclofenac potassium provides faster pain relief, with significant superiority to placebo starting at 60 minutes, compared to 90 minutes for some comparators. 2
• In direct comparison trials, diclofenac-K demonstrated better reduction of accompanying symptoms (particularly nausea) and superior tolerability compared to other acute treatments. 2
• Diclofenac-K 12.5-25 mg showed comparable efficacy to ibuprofen 400 mg for tension-type headache, with number-needed-to-treat (NNT) values of 3.9-4.0 versus 4.5 for ibuprofen. 3

Ibuprofen Dosing and Efficacy

• Ibuprofen 400 mg is more effective than 200 mg, with NNT for 2-hour headache relief of 3.2 versus 6.3 compared to placebo. 4, 5
• Ibuprofen 400 mg provides 2-hour headache relief in approximately 57% of patients versus 25% with placebo. 4
• Soluble formulations of ibuprofen 400 mg provide faster 1-hour relief compared to standard tablets, though 2-hour outcomes are equivalent. 4, 5

Practical Implementation Algorithm

Step 1: Initial NSAID Selection

• Start with either diclofenac potassium 50 mg or ibuprofen 400 mg as a single dose at headache onset. 1, 2, 3
• Choose diclofenac if faster onset (within 60 minutes) is prioritized or if nausea is a prominent symptom. 2
• Choose ibuprofen if cost or widespread availability is the primary concern. 4

Step 2: Ensure Adequate Dosing

• Verify the patient is using therapeutic doses: diclofenac-K 50-100 mg or ibuprofen 400 mg (not 200 mg). 1, 4
• Do not exceed maximum daily doses: ibuprofen 1200 mg/day for over-the-counter use, diclofenac 150 mg/day. 1

Step 3: If Monotherapy Fails

• Add a triptan to the NSAID for patients who do not achieve sufficient pain relief with adequate NSAID dosing alone. 1
• The combination of a triptan plus NSAID provides the greatest net benefit, with 130 more patients per 1000 achieving sustained pain relief compared to triptan monotherapy. 1

Critical Pitfalls to Avoid

Medication Overuse Headache

• Limit NSAID use to fewer than 15 days per month to prevent medication overuse headache. 1, 6
• If acute treatment is needed more than twice weekly, initiate preventive therapy rather than increasing NSAID frequency. 7, 8

Inadequate Dosing

• Avoid using ibuprofen 200 mg when 400 mg is needed—the lower dose has significantly worse efficacy (NNT 6.3 vs 3.2). 4, 5
• Do not continue escalating doses beyond recommended maximums, as this increases toxicity without improving efficacy. 8

Contraindications

• Screen for cardiovascular disease, renal impairment, gastrointestinal ulcer history, and anticoagulant use before prescribing either NSAID. 1
• In patients with NSAID contraindications, use acetaminophen 1000 mg as an alternative, though it has lower efficacy. 1

When to Escalate Beyond NSAIDs

• If adequate-dose NSAID monotherapy fails after 2-3 headache episodes, add a triptan rather than switching between NSAIDs. 1
• Consider CGRP antagonists (gepants) or lasmiditan only after combination triptan-NSAID therapy has failed. 1, 6
• Never use opioids or butalbital-containing compounds for routine headache treatment due to dependency risk and rebound headaches. 1, 6, 8