Acetaminophen (paracetamol) for migraine

What acetaminophen is used for

Acetaminophen is a non-opioid painkiller and is not an NSAID. The Tylenol Extra Strength label lists it for minor aches and pains due to headache and other causes, and for fever. Migraine is not named on that label. Other products and countries differ. The dose comes from the product label or a prescriber.

Guidelines do mention it for migraine:

• NICE CG150 lists paracetamol as a single-medicine option, and as a partner to an oral triptan.
• American Headache Society, 2021, as reported by MDedge, lists acetaminophen among options for mild to moderate attacks.

Cochrane results at 2 hours

Derry 2013 reviewed 11 studies with 2,942 participants and 5,109 attacks. Results are for the single dose studied.

Outcome	Paracetamol	Placebo	Number needed to treat
Pain-free at 2 hours	19%	10%	12
Headache relief at 2 hours	56%	36%	5.0
Headache relief at 1 hour	39%	20%	5.2

Adverse event rates were similar to placebo, and paracetamol alone caused no serious adverse events in the trials.

The review also looked at paracetamol with the antiemetic metoclopramide against oral sumatriptan and found no significant difference in headache relief at 2 hours. No 2-hour pain-free data were available for that comparison.

Liver warning and other label warnings

The Tylenol Extra Strength label states that severe liver damage may occur:

• above the daily amount printed on the label;
• with any other medicine that contains acetaminophen;
• with 3 or more alcoholic drinks every day.

Other points on that label:

• acetaminophen may cause severe skin reactions, such as reddening, blisters or rash;
• do not use with an allergy to acetaminophen or an inactive ingredient;
• ask a doctor first with liver disease or when taking warfarin;
• ask a health professional first if pregnant or breastfeeding;
• stop and ask a doctor if pain gets worse or lasts more than 10 days.

Acetaminophen is also an ingredient of Excedrin, so a product list matters here.

Monthly limit

ICHD-3 has a separate subform for paracetamol overuse. Its limit is the one for non-opioid painkillers: 15 or more days a month for more than 3 months. ICHD-3 regards all non-opioid painkillers as one class, so days with acetaminophen and days with an NSAID add up against the same 15. Products that add caffeine or an opioid belong to a different group, with a limit of 10. Count both with the medication days counter.

In a headache diary

Write the product name, not only “painkiller”. The name shows whether the medicine was acetaminophen alone or a combination, and the two count against different limits. Record the pain at 1 and at 2 hours if you want to compare with the table above.