Nurofen - headache treatment

It is perhaps extremely difficult to find a person who is unfamiliar with the feeling of pain in the head. Indeed, in our difficult times, when stress lurks at every turn, many of us fall victim to it. Moreover, over the past few decades, the prevalence of this unpleasant symptom has increased (Stovner LJ, Andree C., 2010). It should be noted that headaches can be caused by various reasons, depending on which their nature and intensity differ. However, no matter what the headache is and no matter what causes it, it remains a factor that can, at a minimum, ruin your mood and disrupt your work process. But you don’t have to endure a headache! What can a pharmacist advise in this situation?

Headache is a very common symptom. Thus, according to WHO, during the year 80% of the European population reported at least one attack of tension headache, and migraine - 14.9%. Interestingly, the fair sex suffers from headaches much more often than men (Manzoni GC, Stovner LJ, 2010). Thus, approximately every second person experiences a headache at least once a year. And comes with this problem...

As studies show, among patients suffering from headaches, the proportion of those who resort to self-medication is high. The prevalence of self-medication varies both depending on the region, reaching 89% in some countries (Naito Y. et al., 2009; Shehnaz SI et al., 2013), and depending on the age of the patient. For example, 43–51% of adolescents used analgesics at least once within 1 month and almost 80% of elderly patients resort to painkiller self-medication for headaches at least once a year (Lagerlov P. et al., 2009; Bronshtein A.S. ., Rivkin V.L., 2001). In this context, pharmaceutical care becomes of great importance in the work of a pharmacist, since it is often the primary pharmacist who is approached by patients with headaches.

The pharmacist must carefully question the pharmacy visitor not only about the nature and intensity of the pain, but also about the presence of accompanying symptoms, while the minimum that needs to be paid attention to and advised to see a doctor:

intolerance to light and sounds;
weakness, dizziness, sudden loss of balance or falling, loss of sensation or tingling sensation, difficulty speaking, confusion, vision problems;
increased body temperature, intermittent breathing, stiff neck, rash;
severe nausea and vomiting.

It is necessary to advise the visitor to consult a doctor if the headache is unusually intense, occurs as a result of a head injury or accident, and if the headache does not stop for more than 72 hours after taking an anesthetic.

A decent answer for headaches

Today, nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to relieve headaches, which, along with their anti-inflammatory effect, have a pronounced analgesic effect. One of the most studied representatives of this class of drugs is ibuprofen. First synthesized in 1962, the original ibuprofen is available on the European market under the brand name Nurofen®.

A strong evidence base based on data from numerous clinical studies and more than half a century of practical experience is an important argument in favor of using Nurofen® (active ingredient ibuprofen).

What is Nurofen syrup and tablets for?

The action of Nerofen is explained by the presence of ibuprofen in the composition, which, by acting on the thermostat in the brain, relieves fever and returns the temperature to normal values.

In addition, ibuprofen inhibits the synthesis of prostaglandins, which are mediators of pain. Which explains its analgesic effect. This is why Nurofen is indicated for:

high body temperature;
toothache;
headache;
muscle pain;
for adverse reactions after DTP.

Why Nurofen®?

Ibuprofen has undergone many large, randomized, placebo-controlled studies to examine its effectiveness and safety profile, including for various types of headaches, particularly tension-type headaches and migraines. According to the results of a double-blind, randomized, placebo-controlled study, the onset of action of ibuprofen (400 mg) for tension headaches was noted as early as 15 minutes after administration (Schachtel BP, Thoden BP, 1988).

When using ibuprofen (the original drug Nurofen®), a rapid achievement of the maximum concentration of the active substance in the blood (35–45 minutes) and a short half-life (2 hours) without the formation of toxic metabolites are noted, which underlies its safety profile. The good duration of the analgesic effect (up to 6–8 hours) of ibuprofen allows you to achieve the desired result after taking the first dose (van den Anker JN, 2013).

It should be noted that ibuprofen is more effective compared to many other NSAIDs and non-narcotic analgesics. Thus, ibuprofen (400 mg) is significantly more effective in relieving tension headaches compared to paracetamol (1000 mg). In addition, patients receiving ibuprofen experienced an earlier and more complete reduction in pain intensity compared to the group taking paracetamol (Schachtel BP et al., 1996).

The onset of the effect 1 hour after the use of ibuprofen (200 mg) for headache is more pronounced compared to acetylsalicylic acid (500 mg) (Nebe J. et al., 1995). In addition, ibuprofen is as effective in relieving headaches as diclofenac, naproxen and ketoprofen with a more optimal safety profile (Lange R., Lentz R., 1995; Kubitzek F. et al., 2003).

Along with its proven rapid onset of action and effectiveness for headaches, ibuprofen has also been shown to be associated with fewer side effects than many other NSAIDs, as evidenced by numerous studies. Thus, taking ibuprofen is associated with a lower risk of side effects from the gastrointestinal tract compared to ketoprofen, piroxicam, naproxen, acetylsalicylic acid and some other NSAIDs (Henry D. et al., 1996; Castellsague J. et al., 2013 ).

If we talk about the risk of adverse reactions when using ibuprofen, then according to the results of a Cochrane review, it is comparable to that when taking placebo (Rabbie R. et al., 2010).

Thus, ibuprofen is the drug of choice among NSAIDs for the relief of tension-type headaches and the first-line drug in the elimination of migraine in children and adults according to the recommendations of the European Headache Federation, since it is effective while having a more acceptable safety profile ( Verhagen AP et al., 2006; Steiner TJ et al., 2007).

The successful balance of effectiveness and safety profile, confirmed by data from numerous studies, as well as the experience of use by doctors in many countries, allows us to state that ibuprofen is a rational choice for eliminating headaches of varying nature and intensity.

New opportunities in the treatment of headaches in general medical practice

Headache (HE) is the most common complaint in medical practice among patients with a wide variety of diseases. It should be noted that out of fifty different diseases, headache can be the leading (and sometimes the only) complaint. HD is widespread, occurring, according to various sources, in 50–85% of residents of different ages, and its occurrence and development can be determined by both somatic and mental factors. Up to 50% of all consumers resort to self-medication for headaches [1].

All this makes us consider the problem of diagnosing and treating hypertension as a general medical, interdisciplinary task that deserves the attention of doctors of all specialties, a task, primarily for specialists in general medical practice.

Tension headache

A tension headache occurs at least once in every person’s life. There is an episodic form of TTH - it can last from several hours to 7-15 days - and a chronic form of TTH - recorded up to 180 days a year. One of the most common causes of tension-type headache is the so-called “office syndrome” (this is facilitated by: incorrect posture during prolonged work at the computer, stress, sleep disturbance, lack of rest, etc.) [2]. Researchers attribute particular importance to the “muscle factor” in the occurrence of tension-type headaches, since incorrect posture that accompanies stress can cause muscle tension [2–4]. Because as a result of prolonged muscle tension, pressure points, or “trigger points,” are formed in the muscles, leading to the local synthesis of inflammatory mediators - prostaglandins. In turn, peripheral nerve endings become more sensitive to pain impulses, and increasing pain signals lead to the perception of these processes in the form of referred tension headache [2, 4–5].

TTH usually has a painful “aching” character, covers the entire head, and is sometimes accompanied by a feeling of nausea, dizziness and/or other signs of emotional disorders (increased irritability, decreased mood, fatigue, poor sleep, severe autonomic disorders, etc.).

Diagnostic criteria:

Localization: diffuse, bilateral with severity in the occipital-parietal or parietal-frontal regions.
Character: monotonous, squeezing (like a “helmet”, “helmet”, “hoop”), practically never pulsating.
Intensity: moderate, less often intense, usually does not increase with physical activity.
Accompanying symptoms: soreness of the pericranial muscles and muscles of the collar zone, neck, shoulder girdle and loss of appetite (often), nausea, photo- or phonophobia (rarely).
Combination with other algic syndromes (cardialgia, abdominalgia, dorsalgia, etc.) and psychovegetative syndrome, with a predominance of emotional disorders of a depressive or anxiety-depressive nature.

Migraine

Migraine is a periodically recurring paroxysmal condition, manifested by attacks of intense headache of a pulsating nature, in one (rarely in both) half of the head (mainly in the frontal-temporal-parietal-orbital region) in combination with other non-painful manifestations (nausea and/or vomiting, intolerance bright lights, loud noises, emotional disturbances, aura symptoms, drowsiness and lethargy after an attack). The possible duration of an attack is from 1–2 to 72 hours.

There are migraine without aura (simple migraine) and migraine with aura (classic). An aura is a complex of neurological symptoms that occurs immediately before or at the very beginning of a migraine headache.

Auras are distinguished: ophthalmic - with visual disturbances (zigzags, sparks, flickering spiral-like contour); hemiparesthetic - paresthesia or a feeling of numbness that occurs locally and slowly spreads to half the body; paralytic - in the form of unilateral weakness in the limbs; aphasic - in the form of speech disorders, etc. It should be remembered that migraine can have complications: status migraine (duration of attack more than 72 hours) and migraine stroke.

Diagnostic criteria

Migraine without aura

Headache has at least two of the above symptoms (unilateral localization; pulsating nature; moderate or significant intensity of headache, reducing the patient’s activity; headache worsening during monotonous work or walking).
At least five “attacks” of headache, with each duration (without treatment or with unsuccessful treatment) from 4 to 72 hours.
The presence of at least one of the accompanying symptoms (nausea, vomiting, sensitivity to light and/or sound).

Migraine with aura

GB has a minimum of 2 attacks (meeting the criteria for “Migraine without aura”).
Migraine attacks have: complete reversibility of one or more aura symptoms; none of the aura symptoms last more than 60 minutes; the duration of the “light” interval between the aura and the onset of headache is less than 60 minutes.

Treatment of headache

In the treatment of hypertension, various types of medications are used, the most frequently used of which are the most accessible to patients - simple (non-narcotic) analgesics and non-steroidal anti-inflammatory drugs (NSAIDs). From the group of NSAIDs, ibuprofen is most often used in the treatment of hypertension, and from the group of non-narcotic analgesics - paracetamol.

General criteria for choosing NSAIDs in the treatment of hypertension are: rapid action (complete cessation of headache); effectiveness (no recurrence of headache); safety and good tolerability. It was the selection criteria that formed the current recommendations for choosing NSAIDs in the treatment of hypertension: it is more effective to use analgesics at the beginning of an episode of headache, using fast-acting forms of analgesics; and also use the maximum initial dosage in order to prevent relapse and repeated use for the prevention of abuse headaches, it is necessary to limit the doses of analgesics containing barbiturates - up to 4 times a month, simple analgesics and NSAIDs - up to 15 doses per month, and also limit drugs with caffeine content, avoid drugs containing metamizole sodium) [6–7].

Treatment of tension-type headache

When treating TTH, it should be remembered that the source of TTH is the release of prostaglandins, key mediators of inflammation. Therefore, the choice of drug for the treatment of tension-type headache is aimed at its cause, at suppressing the synthesis of prostaglandins. Based on the mechanism of action, NSAIDs are the first choice drugs for the treatment of TTH [4, 14–16].

Thus, when studying the comparative effectiveness of treating TTH with drugs, ibuprofen proved its effectiveness on a par with other NSAIDs (Diclofenac, Naproxen, Ketoprofen); it was proven [17–18] that ibuprofen brings significant relief in TTH within 30 minutes after its administration to a larger number of patients (20% of cases) than paracetamol (12.5% of cases). And it is ibuprofen that provides complete relief of TTH 3 hours after its administration in the majority of patients (75%), compared with paracetamol (32%) [19].

The new original drug Nurofen Express forte is presented in a unique format (capsules with a liquid center), thanks to which the drug has high absorption, and its maximum concentration in the blood (Tmax) is achieved in 30–40 minutes. The enhanced formula contains ibuprofen - 400 mg and targets the source of pain. Currently, the drug Nurofen Express forte is considered the best drug in the Nurofen “line”; it is recommended for use from the age of 12, which is important, given the frequency of headaches in adolescence.

Nurofen Express forte 400 mg begins to eliminate headaches after 15 minutes [20], and its fast-acting form and dosage of 400 mg has the highest efficacy rate, since the earliest achievement of a high concentration of ibuprofen in the blood leads to faster pain relief [21].

Nurofen Express forte (400 mg) has a more pronounced analgesic effect than 1 gram of paracetamol [22–23], or a low dose of ibuprofen (200 mg) compared to an average dose of acetylsalicylic acid (500 mg) [24].

When comparing the risks of adverse events, as well as toxicity in the gastrointestinal tract, Nurofen Express forte with other drugs that aggressively affect the gastrointestinal mucosa (piroxicam, ketoprofen, indomethacin, diclofenac, naproxen, acetylsalicylic acid), showed a high safety profile, accordingly, the lowest risk for undesirable consequences [25–26].

Thus, the drug Nurofen Express forte meets all the criteria for choosing an NSAID: namely “Fast” (begins to act after 15 minutes); “Effectiveness” (contains an effective dose of 400 mg of ibuprofen in one capsule with a liquid center); “Safety” (has the most favorable safety profile among NSAIDs). Nurofen Express forte, according to European standards, can be recommended as the first choice drug for headaches [14–15, 27–30].

Migraine treatment

Migraine, although it ranks second in prevalence, is, however, more pronounced in terms of severity of manifestation and subjectively difficult to tolerate for headache sufferers.

During clinical studies, it was noted that the optimal result in relieving hypertension is achieved by a combination of ibuprofen and paracetamol, which is widely used and considered safe in appropriate doses [8–9]. It is important to note that pharmacokinetic interactions between ibuprofen and paracetamol have not been documented, and no additive effects have been observed from the combined use of these two drugs [10–11].

Ibuprofen and paracetamol are reasonably considered to be relatively safe with a proven analgesic effect, which allows their use in multicomponent analgesics [9, 12–13]. At the same time, a combined drug of ibuprofen and paracetamol allows not only to use the advantages of the two drugs, but also to avoid the disadvantages and dangers of independent combined prescription of NSAIDs [10–11].

In this regard, the drug Nurofen MultiSymptom is interesting, which relatively recently appeared in the Nurofen “line” and is positioned as a “special remedy for migraines”, since its high effectiveness (in terms of the speed of onset of therapeutic effects and elimination of the severity of headache symptoms) is associated with a successful combination of its constituents components: ibuprofen - 400 mg and paracetamol - 325 mg. These components affect the central and peripheral mechanisms of pain syndrome formation and have a rapid, pronounced analgesic effect [9, 12], since it is the combination of ibuprofen and paracetamol that provides a higher analgesic effect due to the combined inhibition of COX types 1–2, which is noticeably superior in effectiveness NSAID monotherapy. The results of randomized, double-blind, placebo-controlled studies for the treatment of acute pain give grounds to conclude that the drug is superior in analgesic efficacy, duration of action and time of development of analgesia to its individual ingredients and placebo [9, 12–13]. It is worth noting that both components of the drug Nurofen MultiSymptom are recommended by the European Neurological Federation and the American Society for the Study of Hypertension as the drugs of choice for the relief of migraine attacks; in addition, studies show that repeated use of the drug is required much less frequently, and the rate of recurrence of a migraine attack is significantly lower [9 , 12–13].

It should also be understood that in relieving hypertension, the use of any drug is more effective if treatment is started earlier (for migraine with aura - at the stage of aura appearance, for simple migraine - from the moment the headache appears), at the height of the attack - most medications are ineffective.

Thus, the attention of doctors should be focused on the use of drugs in the most favorable period, from the point of view of prognosis. It is during this period that non-narcotic analgesics and non-steroidal anti-inflammatory drugs are effective in many patients with rare migraine attacks.

Despite the fact that the use of triptans is currently considered one of the promising areas in the treatment of migraine, it is difficult to use these drugs in general medical practice (especially in underexamined patients). In most cases, one should resort to a stratified approach “from simple to more complex”; this gives every reason to use an effective combination of NSAIDs and analgesics for migraine headaches (Fig. 2).

It is known that significant disadvantages of triptan therapy are:

Possibility of prescribing only with a confirmed diagnosis of migraine;
contraindication for use during aura and more often than 9 days a month;
ability to cause dependence;
prescription dispensation.

In studies where ibuprofen 400 mg was used to treat migraine, it reduced nausea and vomiting, this is likely due to ibuprofen's ability to reduce platelet aggregation or prostaglandin synthesis, both of which are involved in the development of migraine symptoms [31].

conclusions

HD occurs quite often in the population, regardless of gender and age.
Among primary headaches, tension headache is the leader, and migraine is the second most common headache.
The new drug Nurofen Express forte can be considered as the first choice drug for tension-type headache, which has a highly effective, rapidly onset (begins to act within 15 minutes) effect with a proven most favorable safety profile among NSAIDs, and the use of which is an ideal solution for tension-type headache.
The new drug Nurofen MultiSymptom contains a combination of ibuprofen and paracetamol in doses that reliably relieve a migraine attack faster and more effectively compared to the individual components of the drug [9, 12, 13], which makes it possible to talk about an effective solution to the problem of migraine, and the components contained in it (ibuprofen and paracetamol) correspond to a high level of evidence of effectiveness and are recommended as the drugs of choice for the treatment of migraine.

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V. G. Moskvichev*, Candidate of Medical Sciences Yu. G. Petrova**, Candidate of Medical Sciences R. M. Mamin***

* GBUZ PKB No. 4 named after. P. B. Gannushkina DZM, Moscow ** State Budgetary Healthcare Institution JSC City Clinical Hospital No. 5, Astrakhan *** State Budgetary Educational Institution of Higher Professional Education of the State Medical University "MSCh", Astrakhan

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If Nurofen does not bring down the temperature: what to do

When the thermometer rises above 39˚C, absorption of substances from the stomach may stop. This means that taking medications orally may not have an effect. This happens especially often when the patient washes down the tablet or syrup with cold water. Once in the stomach, cold liquid forces the vessels of the gastric walls to contract, as a result of which they cannot fully pass substances through their walls.

In this case, doctors recommend giving preference to rectal suppositories at high temperatures exceeding 39˚C. The suppository, once in the rectum, quickly dissolves, and ibuprofen immediately enters the bloodstream through the intestinal walls. After 30-40 minutes, the patient’s temperature begins to decrease.

How many times can Nurofen be given to a baby?

The effect of the drug begins an hour after the first dose. The decrease in temperature can continue for up to half an hour until the values drop to normal levels. The antipyretic effect can last up to 8 hours. However, with severe inflammatory processes, the fever may return after 4-5 hours. An infant can be re-given a single dose of the drug both in the form of suppositories and in the form of syrup after 4 hours if the temperature begins to rise again. A baby can receive up to 5 permissible single doses per day.