Outpatient Pain Medication for Headache in Patient with Codeine Allergy

First-Line Treatment Options

The American College of Physicians recommends NSAIDs as first-line therapy for headache pain, with evidence showing they are more effective than codeine-acetaminophen combinations and have a safer side effect profile 2
Ibuprofen 400-600 mg every 6 hours (maximum 2400 mg daily) is a recommended NSAID option for headache treatment 1
Naproxen 500 mg initially, then 250 mg every 6-8 hours (maximum 1250 mg daily) is another recommended NSAID option for headache treatment 3
Aspirin 500-1000 mg every 4-6 hours (maximum 4000 mg daily) can be used as an alternative NSAID option for headache treatment 3
Acetaminophen 1000 mg every 6 hours (maximum 4000 mg daily) is an alternative if NSAIDs are contraindicated, as recommended by the American College of Physicians 4, 3

For moderate to severe headache with migraine features, the American College of Physicians recommends adding a triptan to the NSAID or acetaminophen regimen 4, 5
The combination of a triptan with an NSAID shows greater efficacy than either medication alone, with a strength of evidence supporting this recommendation 6

The American College of Physicians recommends avoiding opioids (including those without codeine) for headache treatment due to risk of medication overuse headache, dependency, and reduced efficacy over time 4
Butalbital-containing medications should also be avoided for headache treatment, as recommended by the American College of Physicians 4
For patients who don't respond to NSAIDs and triptans, CGRP antagonists (gepants) such as rimegepant or ubrogepant may be considered, with a moderate strength of evidence supporting this recommendation 7
Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans), highlighting the importance of responsible medication use 7

If the patient has contraindications to NSAIDs (such as renal impairment, gastric ulcers, or bleeding disorders), acetaminophen should be used as the primary analgesic, as recommended by the American College of Physicians 4
For pregnant patients with headache, acetaminophen is the safest first-line option, with a high strength of evidence supporting this recommendation 8
For patients with severe migraine not responding to other treatments, dihydroergotamine may be considered if there are no cardiovascular contraindications, with a moderate strength of evidence supporting this recommendation 7