OTC Pain Relievers--How Physicians Use Them for Maximum Relief

Disclaimer:  The information below is only for educational purposes to provide a general idea of what medications should be stockpiled and which are indicated for various conditions.  A licensed physician should always be consulted before taking any medication, even those available over-the-counter.

Sometimes we get the idea that over-the-counter pain relievers are all basically the same.  While occasionally any one of two or three choices will work for what ails us at the moment, it really behooves us to gain a better understanding of what works best in any given situation.  So let's review the most common OTC pain relievers.

Advil is the trade name for ibuprofen.  It is taken for reducing pain, fever, inflammation, painful periods, rheumatoid arthritis, osteoarthritis, kidney stones, dental pain, migraines, and even treating patent ductus arteriosis in a premature baby.  Side effects include heartburn and rash, and it may worsen asthma.  It may increase the risk of heart, kidney, and liver failure.  It is not for use during pregnancy.  Advil is on WHO's List of Essential Medicines.  It can interfere with the anti-platelet effect of low-dose aspirin and is a weak photo-sensitizing agent.  Chronic use is associated with an increased risk of heart attack, stroke, and high blood pressure.  If poisoning is suspected, treat with activated charcoal.  Inducing vomiting is not recommended.  One study showed that people who regularly used ibuprofen reported a 38% less risk of developing Parkinson's.  However, the effect of long-term use on the urinary and gastrointestinal tracts should be noted.  And ibuprofen can be especially rough on the kidneys if the patient is dehydrated.   Prescription strength Advil/ibuprofen/Motrin is 800 mg per dose taken at six-hour intervals for a maximum of three doses in a 24-hour period.  Total daily dosage is 2400 mg. 

Aspirin is one of those drugs that would not be approved by the FDA today because it does too many things.  Because it is a blood thinner and can be used to stop a heart attack, chewable baby aspirins should be part of every medical kit.  Aspirin can cause stomach upset and may worsen asthma.  It should not  be used in the last trimester of pregnancy and should not be used for children with infections due to the risk of Reyes syndrome.  Aspirin is on WHO's List of Essential Medicines.  It is generally not as effective against pain as ibuprofen, nor is it very effective for pain due to muscle cramps, bloating, gastric distention, or acute skin irritation.  Aspirin works synergistically with caffeine.  Effervescent formulations work faster than tablets and are more effective for migraines.  Topical aspirin may be effective for some types of neuropathic pain.  Aspirin is more effective for tension headaches and less effective on other types of headaches.  It is most effective at stopping migraines when they are first beginning.  An overdose is treated with activated charcoal and IV saline.

Aleve (naproxen sodium/naprosyn) is similar to Advil and is taken for relieving pain, fever, swelling, and stiffness.  It is generally safe for use by nursing mothers.  It may cause side effects of rash, heartburn, and stomach ulcers.  Aleve is used to treat migraine, osteoarthritis, rheumatoid arthritis, psoriatic arthritis, kidney stones, gout, tendinitis, bursitis, and menstrual cramps.  It is not indicated for diabetic neuropathy.  Aleve may have antiviral activity against influenza.  Aleve may be used to differentiate between infectious fevers and neoplastic (connective tissue) fevers, as in cancer.  Heavy use may cause end stage renal disease and kidney failure.  Aleve should be taken with food.  Aleve may interact with blood thinners and prednisone.  Aleve has been an over-the-counter drug in the US since 1994 in 220 mg tablets, but remains prescription only in much of the rest of the world.    Regular OTC usage is one 220 mg tablet every 8-12 hours.  Prescription dosage should not exceed 1250 mg in the first 24 hours; subsequent daily doses should not exceed 1000 mg.  

Excedrin/Vanquish is a combination of acetaminophen, aspirin, and caffeine used primarily for headaches, but is also used for arthritis, back ache, colds, menstrual cramps, and muscle aches.  This aspirin/acetaminophen/caffeine combination is as effective in treating migraines as lower doses of sumatriptan. Excedrin has more acetaminophen, aspirin, and caffeine per dose than Vanquish.  Excedrin is sold in "extra strength" and "migraine" formulas.  There is no regular strength.  And the "extra strength" and "migraine" dosages and formulas are exactly the same, but if the bottle says "migraine" on it, it costs substantially more.  This is just one example of repackaging as marketing, and the Excedrin manufacturer Novartis was sued over this.  Manufacturers do the same thing with Benadryl/diphenhydramine hydrochloride.  It's one price if sold as an allergy medication and about double if sold as a sleep aid.

Meloxicam is a pain reliever similar to Tylenol but is available by prescription only in the US.  However, I include it here because it has an important advantage over the other OTC pain relievers.  US combat troops are issued this pain reliever for their IFAKs because it does not interfere with platelet function, i.e., blood-clotting, it is more effective at relieving pain than Tylenol, and it is taken only once per day.  Meloxicam is an NSAID most often prescribed for treating arthritis and tendinitis.  It should be taken with food and is better than ibuprofen for moderate to severe pain.  Meloxicam should not be used by individuals with asthma or by pregnant women.  Long-term use may cause liver damage and increase the risk of heart attack and stroke.  It may reduce kidney function and should be used with caution in individuals with heart failure.  Meloxicam may contribute to insomnia, bladder infections, and URIs.  The beginning dose is 7.5 mg/day.  The maximum daily dose is 15 mg, taken once per day.

Motrin.  Exact same thing as Advil/ibuprofen.

Tylenol (acetaminophen in the US, paracetamol in the UK) is most often indicated for treating pain, fever, allergies, cold, cough, flu, and headache.  It is considered the most effective fever reducer of the major pain-relieving formulas.  It reduces the perception of pain, but does little to treat the cause of pain.   Acetaminophen is quite safe, as long as it is used as directed and there is no underlying liver or kidney damage.  Complications arise from overdoses, which are generally unintentional.  These overdoses most often occur because acetaminophen is found in so many OTC medications.  Before July 2011, the maximum daily dose listed on the packaging was 4000 mg, but that year manufacturers reduced that maximum to 3000 mg per day.  This was a liability defense protection move; the FDA still lists the maximum dose as 4000 mg per day.  Acetaminophen tablets come in several strengths:  325 mg regular strength, 500 mg extra strength, and 650 mg arthritis pain (but this last caplet is extended or sustained release over the day and needs to only be taken every twelve hours). Tylenol-3 is 300 mg acetaminophen and 30 mg of codeine, a controlled substance.

Most of the above pain relievers become noticeably effective within 30 to 60 minutes.  Children's chewables--all chewables--enter the bloodstream much more quickly and thus begin acting faster.  This can be especially important when attempting to stop a migraine and stocking some (unfortunately, very expensive) children's chewables may be worthwhile.

Most of the above pain relievers are blood thinners or anti-coagulants and should not be administered when bleeding is or could become an issue.  For this reason, combat troops are not allowed to use anything but acetaminophen or meloxicam.  All of the OTC medications listed above, except meloxicam (which is not OTC in the US) can be purchased very cheaply in large quantities through Amazon and Sam's Club.  For some reason, Amazon Prime Pantry has many of these medications even cheaper.  It may be worthwhile to get a free trial of Amazon Prime Pantry and order all your OTC meds at once. 

Bear in mind that physicians seem to have their own favorites, medications that in their experience work better than others.  And some people also respond better to one medication than another.

One study showed that any use of NSAIDs (even Tylenol) by pregnant women increased the risk of miscarriage 2.4-fold.

As mentioned in the Shelf-Life Extension Program post, liquid medications diminish in strength soon after their use-by date.  However, tablets and capsules are effective years beyond their stamped use-by dates.  

Combining Tylenol and Advil:  Yes, it is safe.  They have different mechanisms of action.  Tylenol is cleared by the liver; Advil is cleared by the kidneys.  The combination of these two medications has been shown to be more effective than Vicodin or Norco for treating dental pain.  This is most effective when the doses are alternated.  For example, take Tylenol at 6AM, 2PM, 10PM; Advil at 10AM, 6PM, 2AM.  Same idea for goes for combining Tylenol and Aleve. Do not combine Advil and Aleve.

What if any of the above medications cause you stomach pain?  According to Dr. Cynthia Koelker, author of Armageddon Medicine (and this is info from one of her lectures, not her book), you can take ranitidine (Zantac) one hour before taking the pain reliever.  If any of the above medications cause nausea, take meclizine or dimenhydrinate (Dramamine) one hour before taking the pain reliever.

To reiterate the disclaimer above:  a licensed medical provider should be consulted before taking any medication.  The information provided herein is only for education about which drugs are most useful and likely to be suggested by a physician and therefore desirable to keep on hand in a grid-down situation.

Links to related posts:  
Benadryl 
Meclizine
Ranitidine
Armageddon Medicine 

For further reading:
https://www.goodrx.com/blog/is-it-safe-to-take-tylenol-acetaminophen-with-advil-or-motrin-ibuprofen/
https://www.drugs.com/dosage/ibuprofen.html
https://www.drugs.com/meloxicam.html
https://www.drugs.com/dosage/acetaminophen.html
https://www.drugs.com/aleve.html