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Ask the Pharmacist: Over-the-counter Medications – How to Choose

All questions answered by:
Richard Wenzel, PharmD
Diamond Headache Clinic Inpatient Unit
St. Joseph’s Hospital, Chicago, IL

Approximately 15 million migraine sufferers exclusively use over-the-counter medications to treat their illness. This preference for OTC drugs results from several factors, including the ease of purchasing OTC products, their low cost (especially in comparison to prescription drugs), and their generally wide safety margin. While many patients successfully treat their migraine attacks with OTC agents, a significant proportion of sufferers fail to obtain adequate relief from these medications.

Are OTCs Right for You?

Educating yourself about when OTC drugs are appropriate or inappropriate for your migraine attacks will obviously improve overall care. Before purchasing an OTC agent, you should ask yourself a couple of key questions:

  1. What percentage of your migraine attacks are debilitating? Signs of debilitation include an inability or reduced ability (by at least 50%) to perform your usual daily work, home and social activities. The need for bedrest is always a sign of debilitation. If the majority of your migraine attacks cause debilitation, OTC medications are unlikely to provide effective relief. You should consider making an appointment with a healthcare provider because prescription medications are most likely your best option.
  2. How many days per month are you completely headache free? While your top concern may be your debilitating attacks, even those days with “small” or “mild” headaches are important to consider. If you are headache-free 15 or fewer days per month (in other words, you have a headache more than 15 days per month), OTC products may not be your best option and you should consider seeing a healthcare provider. Furthermore, patients with this frequency of headache are at risk of over-using OTC drugs, which can ultimately cause rebound medication overuse headaches.

Consistently recording information in a diary is an effective way to determine what percentage of attacks are debilitating and your total number of headache days. (A headache diary can be downloaded for free from the NHF Web site, Ideally, at least one or two months of this information should be recorded before answering the two key questions asked above. If your diary information reveals that OTC drugs are appropriate for you, the next question you have to answer is which particular product should you use?

Choosing Between Products

An enormous selection of OTC agents is available for sale at your local pharmacy, which can make choosing difficult. The majority contain either acetaminophen, aspirin, an anti-inflammatory drug (e.g., ibuprofen, naproxen or ketoprofen), caffeine or some combination of these ingredients. The only brand-name OTC products approved by the Food and Drug Administration (FDA) for the treatment of acute migraine attacks are Excedrin Migraine® (acetaminophen, aspirin, and caffeine), Advil Migraine® (ibuprofen) and Motrin Migraine Pain® (ibuprofen).

No OTC medication has been demonstrated as superior or inferior to another OTC medication for the treatment of acute migraine attacks, thus your selection may depend on other factors. Cost is a big consideration. For example, at my local pharmacy a bottle of brand name ibuprofen containing 30 tablets costs $6.00, while a bottle of generic ibuprofen containing 100 tablets costs $5.00. Obviously the generic bottle gives you more pills for less money, with no known difference in effectiveness or adverse effects.

The presence of caffeine is another consideration. Caffeine can speed the absorption of the other medications in a drug combination, decreasing the time needed to obtain relief from a migraine attack. However, people already consuming caffeine every day (in coffee, sodas, etc.) may actually experience negative effects from consuming even more caffeine. Excessive caffeine intake can in, some cases, contribute to worsening the headache problem.

Whatever OTC product you select, remember to always assess if the medication actually works for you and that it works consistently. For example, if your OTC agent has failed to provide adequate relief in two of the last three treated attacks, it’s time to consider switching to a different OTC medication. If three different OTC products have failed to give you relief, you should consider seeing a healthcare provider for prescription medication. Again, recording information in a diary is the best way to determine if OTC agents are appropriate for your migraine attacks.

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