Is it safe to give naproxen to a 28-year-old woman with a 2–4‑day headache who has ventriculomegaly and a history of congenital hydrocephalus?

Safety of Naproxen in a 28-Year-Old Woman with Ventriculomegaly and Congenital Hydrocephalus

Naproxen is safe to use for short-term headache treatment in this patient, provided there are no contraindications such as renal impairment, active GI bleeding, or aspirin/NSAID-induced asthma. The presence of ventriculomegaly and a history of congenital hydrocephalus does not contraindicate NSAID use.

Clinical Reasoning

Hydrocephalus Does Not Contraindicate NSAIDs

• Congenital hydrocephalus in adults typically presents with chronic, stable ventriculomegaly that has been present since birth or early childhood and does not inherently contraindicate the use of NSAIDs like naproxen. 1, 2, 3
• The primary concerns with NSAIDs relate to cardiovascular, gastrointestinal, renal, and hepatic effects—not to cerebrospinal fluid dynamics or ventricular size. 4
• Adult-onset hydrocephalus patients may experience headaches as a presenting symptom, and standard acute headache treatments including NSAIDs remain appropriate first-line therapy. 1

Naproxen as First-Line Headache Treatment

• Naproxen 500–825 mg is recommended as first-line therapy for mild-to-moderate headache, with evidence supporting its efficacy and safety profile. 5, 6
• The recommended initial dose is 500–825 mg at headache onset, which can be repeated every 2–6 hours as needed, with a maximum of 1.5 g per day. 6
• Treatment should be limited to no more than 2 days per week (≤10 days per month) to prevent medication-overuse headache. 5, 6

Absolute Contraindications to Screen For

Before prescribing naproxen, verify the patient does not have:

• Renal impairment (creatinine clearance <30 mL/min). 6, 4
• Active gastrointestinal bleeding or history of peptic ulcer disease. 6, 4
• Aspirin/NSAID-induced asthma or aspirin-sensitive asthma (cross-reactivity can cause severe bronchospasm). 4
• Severe hepatic dysfunction or active liver disease. 4
• Uncontrolled hypertension or significant cardiovascular disease (NSAIDs may diminish antihypertensive effects and increase CV risk). 4

Monitoring and Safety Considerations

• Patients on long-term NSAID therapy should have hemoglobin/hematocrit checked if they exhibit signs of anemia, as NSAIDs can cause occult GI blood loss. 4
• Hepatic function monitoring is prudent in patients requiring prolonged or high-dose therapy, as rare cases of severe hepatic reactions have been reported. 4
• Advise the patient to report signs of GI bleeding (melena, hematemesis, epigastric pain), unexplained weight gain or edema, or signs of hepatotoxicity (nausea, fatigue, jaundice, right upper quadrant tenderness). 4

When to Escalate Therapy

• If naproxen fails after 2–3 headache episodes, consider switching to a triptan (sumatriptan, rizatriptan) for moderate-to-severe attacks. 6
• If headaches occur more than twice weekly, initiate preventive therapy rather than increasing acute medication frequency. 5

Critical Pitfall to Avoid

• Do not prescribe opioids or butalbital-containing compounds for headache in this patient, as they provide questionable efficacy, carry high risk of dependency, and can precipitate medication-overuse headache. 5, 6