NAPROXEN
Place In Therapy
Randomized-controlled trials found that acetaminophen 1000mg and
naproxen 347mg had similar efficacy from 1 to 6 hours after being taken for
tension-type headache relief and neither was considered superior1. Naproxen did not eliminate headache pain
after 2 hours and when compared to acetaminophen 1000mg, produced a smaller
mean pain intensity difference from baseline than acetaminophen1.
However, when compared to acetaminophen 650mg, naproxen 500mg is more effective5. Other evidence suggests fewer patients may
need a relief medication after administration of naproxen 550mg than
acetaminophen 1000 mg with caffeine 130 mg, which made is the preferred
choice of patients over the combination of acetaminophen with caffeine2.
No difference in adverse events occurred between acetaminophen and naproxen1. Compared to combination acetaminophen and
caffeine or ibuprofen 200mg, naproxen causes fewer symptoms2,3. However, naproxen caused slightly higher
rates of drowsiness and dyspepsia than other medications and higher central
nervous system adverse events compared to aspirin 2,3. However,
overall adverse events appeared minimal3.
Due to its relatively new release to the market as an over-the-counter product, naproxen doses in the literature range from slightly higher up to double the recommended non-prescription dose in Canada. Therefore, patients may see less relief from naproxen if using the 220mg every 8 to 12 hours, as recommended by the manufacturer. Of note, some practitioners recommend naproxen 440mg once daily, which would be closer to the doses used in the literature. In general, there is conflicting evidence and limited research of naproxen for use in TTHs. One large pooled analysis did not consider naproxen as first or second line therapy, while another deemed it an appropriate first line therapy4,5. A conclusion about naproxen’s place in therapy for TTH’s must consider the quality of each study and the corresponding results. In turn, it is reasonable to state that if a patient has no contraindications to acetaminophen 1000mg, than this may be more efficacious than naproxen. For patients with inadequate relief from acetaminophen 1000mg, a trial of naproxen may be more effective than ibuprofen 200mg, but have more gastrointestinal side effects3. Ultimately, the research is limited for use of naproxen in TTH’s, so therapy should depend on patient-specific factors. There needs to be more studies with naproxen 220mg in TTH’s before making any concrete conclusions.
References
1) Prior MJ, Cooper KM, May LG, Bowen DL. Efficacy and safety of acetaminophen and naproxen in the treatment of tension-type headache. A randomized, double-blind, placebo-controlled trial. Cephalalgia. 2002 Nov;22(9):740-8.
2) Pini LA, Del Bene E, Zanchin G, Sarchielli P, Di Trapani G, Prudenzano MP, et al. Tolerability and efficacy of a combination of paracetamol and caffeine in the treatment of tension-type headache: a randomised, double-blind, double-dummy, cross-over study versus placebo and naproxen sodium. J Headache Pain. 2008 Dec;9(6):367-73.
3) Verhagaen AP, Damen L, Berger MY, Passchier J, Merlijn V, Koes BW. Is any one analgesic superior for episodic tension-type headache? J Fam Pract. 2008;55(12):1064-1072.
4) Haag G, Diener HC, May A, Meyer C, Morck H, Straube A, et al. Self-medication of migraine and tension-type headache: summary of the evidence-based recommendations of the Deutsche Migräne und Kopfschmerzgesellschaft (DMKG), the Deutsche Gesellschaft für Neurologie (DGN), the Österreichische Kopfschmerzgesellschaft (ÖKSG) and the Schweizerische Kopfwehgesellschaft (SKG). J Headache Pain. 2011 Apr;12(2):201-17.
5) Woods TM, Dunican KC, Desilets AR. Pharmacotherapy and lifestyle interventions for tension-type headaches. Am J Lifestyle Med. 2009;3(3):238-248.
6) e-CPS. Naprelan. Compendium of pharmaceutical and specialties [Internet]. 2012 [cited 21 Feb 2012]. Accessed from: https://www-e-therapeutics-ca.proxy.lib.uwaterloo.ca/cps.select.preliminaryFilter.action?simplePreliminaryFilter=naproxen+sodium#m700955n00053
7) WHO. Headache disorders. 2004 [updated 2003 Mar; cited 2012 Feb 23]. Available from: http://www.who.int/mediacentre/factsheets/fs277/en/
Due to its relatively new release to the market as an over-the-counter product, naproxen doses in the literature range from slightly higher up to double the recommended non-prescription dose in Canada. Therefore, patients may see less relief from naproxen if using the 220mg every 8 to 12 hours, as recommended by the manufacturer. Of note, some practitioners recommend naproxen 440mg once daily, which would be closer to the doses used in the literature. In general, there is conflicting evidence and limited research of naproxen for use in TTHs. One large pooled analysis did not consider naproxen as first or second line therapy, while another deemed it an appropriate first line therapy4,5. A conclusion about naproxen’s place in therapy for TTH’s must consider the quality of each study and the corresponding results. In turn, it is reasonable to state that if a patient has no contraindications to acetaminophen 1000mg, than this may be more efficacious than naproxen. For patients with inadequate relief from acetaminophen 1000mg, a trial of naproxen may be more effective than ibuprofen 200mg, but have more gastrointestinal side effects3. Ultimately, the research is limited for use of naproxen in TTH’s, so therapy should depend on patient-specific factors. There needs to be more studies with naproxen 220mg in TTH’s before making any concrete conclusions.
References
1) Prior MJ, Cooper KM, May LG, Bowen DL. Efficacy and safety of acetaminophen and naproxen in the treatment of tension-type headache. A randomized, double-blind, placebo-controlled trial. Cephalalgia. 2002 Nov;22(9):740-8.
2) Pini LA, Del Bene E, Zanchin G, Sarchielli P, Di Trapani G, Prudenzano MP, et al. Tolerability and efficacy of a combination of paracetamol and caffeine in the treatment of tension-type headache: a randomised, double-blind, double-dummy, cross-over study versus placebo and naproxen sodium. J Headache Pain. 2008 Dec;9(6):367-73.
3) Verhagaen AP, Damen L, Berger MY, Passchier J, Merlijn V, Koes BW. Is any one analgesic superior for episodic tension-type headache? J Fam Pract. 2008;55(12):1064-1072.
4) Haag G, Diener HC, May A, Meyer C, Morck H, Straube A, et al. Self-medication of migraine and tension-type headache: summary of the evidence-based recommendations of the Deutsche Migräne und Kopfschmerzgesellschaft (DMKG), the Deutsche Gesellschaft für Neurologie (DGN), the Österreichische Kopfschmerzgesellschaft (ÖKSG) and the Schweizerische Kopfwehgesellschaft (SKG). J Headache Pain. 2011 Apr;12(2):201-17.
5) Woods TM, Dunican KC, Desilets AR. Pharmacotherapy and lifestyle interventions for tension-type headaches. Am J Lifestyle Med. 2009;3(3):238-248.
6) e-CPS. Naprelan. Compendium of pharmaceutical and specialties [Internet]. 2012 [cited 21 Feb 2012]. Accessed from: https://www-e-therapeutics-ca.proxy.lib.uwaterloo.ca/cps.select.preliminaryFilter.action?simplePreliminaryFilter=naproxen+sodium#m700955n00053
7) WHO. Headache disorders. 2004 [updated 2003 Mar; cited 2012 Feb 23]. Available from: http://www.who.int/mediacentre/factsheets/fs277/en/