What is the recommended acute naproxen sodium dose for an adult with episodic migraine, and what contraindications (e.g., gastrointestinal ulcer disease, renal impairment, uncontrolled hypertension, anticoagulant use) and alternative therapies should be considered?

Naproxen Dosing for Acute Migraine

For acute migraine treatment in adults, administer naproxen sodium 500–825 mg at migraine onset—ideally when pain is still mild—and repeat every 2–6 hours as needed, with a maximum of 1.5 g per day. 1

Recommended Dosing Strategy

• Initial dose: 500–825 mg of naproxen sodium at the first sign of migraine, preferably when pain intensity is still mild 1
• Repeat dosing: May be repeated every 2–6 hours as needed 1
• Maximum daily dose: 1.5 g (1500 mg) per day 1
• Duration per attack: Can be safely used for up to 3 consecutive days for a single migraine episode 1

Critical Frequency Limitation to Prevent Medication-Overuse Headache

Restrict naproxen use to no more than 2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1

• Using naproxen on ≥15 days per month creates a self-perpetuating cycle that sustains chronic migraine 1
• If you require acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing naproxen frequency 1

Enhancing Efficacy with Adjunctive Therapy

• Add an antiemetic 20–30 minutes before naproxen (metoclopramide 10 mg or prochlorperazine 25 mg) to provide synergistic analgesia and improve outcomes compared to naproxen alone 1
• Treat early when pain is mild: This strategy yields markedly better outcomes—approximately 50% of patients become pain-free at 2 hours when treating mild pain versus only 28% when delaying until pain is moderate or severe 1

Absolute Contraindications

• Renal impairment: Creatinine clearance <30 mL/min 1
• Aspirin/NSAID-induced asthma 1
• Active gastrointestinal bleeding or ulcer disease 1
• Uncontrolled hypertension: NSAIDs can further elevate blood pressure and increase cardiovascular risk 1

When to Escalate Treatment

• If naproxen fails after 2–3 migraine episodes, switch to a triptan (sumatriptan 50–100 mg, rizatriptan 10 mg, or eletriptan 40 mg) for moderate-to-severe attacks 1
• For severe attacks unresponsive to NSAIDs, consider dihydroergotamine (DHE) 1
• Combination therapy: The strongest evidence supports combining sumatriptan 50–100 mg with naproxen 500 mg for moderate-to-severe migraine, which is superior to either agent alone with a number-needed-to-treat of 3.5 for headache relief at 2 hours 1, 2

Clinical Efficacy Evidence

• Naproxen achieves pain-free response at 2 hours in approximately 17% of patients versus 8% with placebo, yielding a number-needed-to-treat of 11 3
• Headache relief (reduction from moderate/severe to mild/none) at 2 hours occurs in 45% with naproxen versus 29% with placebo, with a number-needed-to-treat of 6.0 3
• This modest efficacy means naproxen works as a stand-alone agent in fewer than 2 in 10 patients for complete pain freedom, making it less effective than triptans or combination therapy 3

Common Pitfalls to Avoid

• Do not allow patients to increase frequency beyond 2 days per week in response to treatment failure; instead, transition to preventive therapy while optimizing acute treatment strategy 1
• Never substitute opioids (hydrocodone, oxycodone, codeine) as rescue medications—they have questionable efficacy, high risk of dependence, and cause rebound headaches 1
• Avoid delaying treatment until pain becomes severe; early intervention when pain is mild significantly improves outcomes 1