Can I use etoricoxib (generic etoricoxib) for an adult with episodic tension‑type headache?

Etoricoxib for Episodic Tension-Type Headache

Etoricoxib is not recommended for episodic tension-type headache because it lacks evidence-based support in current clinical guidelines, which instead recommend ibuprofen 400 mg or aspirin 1000 mg as first-line NSAIDs.

Evidence-Based First-Line Treatment Options

The most recent high-quality evidence establishes a clear hierarchy for treating episodic tension-type headache:

• Ibuprofen 400 mg is the recommended first-line NSAID based on superior efficacy (2-hour pain-free rate), favorable safety profile, and cost-effectiveness compared to other NSAIDs. 1, 2

• Aspirin 1000 mg is the alternative first-line NSAID when ibuprofen is contraindicated or not tolerated, with comparable efficacy and safety data. 1

• Diclofenac potassium ranks second in efficacy after ibuprofen in network meta-analysis, achieving a 2-hour pain-free rate with RR 2.61 (95% CrI: 1.53-4.88) versus placebo. 2

Why Etoricoxib Is Not Recommended

• Etoricoxib is absent from all major headache treatment guidelines including the American College of Physicians (2025), American Academy of Family Physicians, and systematic reviews of tension-type headache management. 3, 4, 1

• The NSAIDs specifically evaluated and recommended for episodic tension-type headache are aspirin, ibuprofen, naproxen, diclofenac potassium, and ketoprofen—etoricoxib does not appear in this evidence base. 3, 4, 1, 2

• Etoricoxib is a selective COX-2 inhibitor approved for chronic arthropathies, musculoskeletal pain, and dental pain—not for primary headache disorders. 5

• The 20-hour elimination half-life of etoricoxib makes it unsuitable for acute episodic headache treatment, which requires rapid onset of action (ibuprofen peaks at 1-2 hours). 5

Recommended Treatment Algorithm

Step 1: Initial therapy

• Start with ibuprofen 400 mg at headache onset. 1, 2
• If ibuprofen is contraindicated (renal impairment, aspirin-sensitive asthma, active GI bleeding), use aspirin 1000 mg instead. 1

Step 2: If inadequate response after 2-3 episodes

• Switch to diclofenac potassium or ketoprofen as alternative NSAIDs with proven efficacy. 2

Step 3: Frequency monitoring

• Limit NSAID use to ≤2 days per week to prevent medication-overuse headache. 4, 6
• If headaches occur more than twice weekly, initiate preventive therapy with amitriptyline 30-150 mg/day rather than increasing acute medication frequency. 4, 6

Critical Pitfalls to Avoid

• Do not use triptans, muscle relaxants, or opioids for tension-type headache—these lack efficacy and carry risks of dependency and medication-overuse headache. 4

• Do not substitute etoricoxib simply because it is a COX-2 inhibitor—celecoxib is the only COX-2 inhibitor mentioned in migraine guidelines, and even then only as an alternative NSAID option, not for tension-type headache. 3

• Do not exceed 15 days per month of NSAID use to avoid transforming episodic headache into chronic daily headache through medication overuse. 4

Non-Pharmacological Adjuncts

• EMG biofeedback has documented efficacy for tension-type headache and should be considered alongside pharmacotherapy. 4

• Physical therapy and acupuncture may be valuable options for patients with frequent episodic tension-type headache. 4