The choice of over-the-counter (OTC) pain medications seems to grow by the day. Whether you’re shopping online, at your pharmacy or breezing through a gas station or grocery store, we have lots of – maybe too many – choices.

Maegan Kiser

But what’s the best pill, capsule, gelcap or tablet to pop for what’s hurting? Not every OTC pain reliever works the same way, nor do they work the same for everybody.

We talked to Maegan Kiser, a family nurse practitioner with Novant Health Forsyth Family Medicine in Winston-Salem, North Carolina, about OTC pain meds – when to take them, when to be cautious, when to see a doctor.

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Can you speak to the benefits and drawbacks of OTC pain relievers?

Their benefits are that they’re low-cost and easy to get anywhere. But the drawbacks are the contraindications – or warnings – that come with them. Just because you don’t need a prescription doesn’t mean you can take them anytime for anything.

Before we discuss those warnings, can you explain what NSAIDs are? And what pain meds fall into that category?

NSAIDs are non-steroidal anti-inflammatory drugs, such as aspirin, Motrin, Advil and Aleve, that are used to treat minor aches and pains. I should mention that Tylenol is not an NSAID.

Many NSAIDs – aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn) – are available over the counter. Others – Celebrex, for instance – require a prescription.

You said Tylenol isn’t an NSAID. What is it?

Tylenol is an analgesic – or, simply put, a drug that relieves pain. It’s also known as acetaminophen – a non-aspirin pain reliever used to reduce fever, headaches and other mild aches and pains. (Other OTC medications containing acetaminophen include Dayquil and NyQuil Cold/Flu Relief.) Tylenol is not effective on pain caused by inflammation.

But on the plus side, Tylenol is not known to cause stomach upset – as aspirin sometimes can – and it is generally safer for children than other OTC pain relief. It comes with fewer side effects.

Tylenol comes with a different warning than NSAIDs. You should avoid taking it if you have liver disease or are a heavy alcohol drinker because it can affect the liver. And when you’re pregnant, you should not take ibuprofen for minor aches and pains. Tylenol is OK to take during pregnancy.

Are there differences among those three groups – aspirin, ibuprofen and naproxen? What are the benefits and shortcomings of each?

Ibuprofen, naproxen and aspirin are all NSAIDs and all work, more or less, the same way.

Acetaminophen (Tylenol) works by blocking pain signals, whereas NSAIDS work by reducing pain and inflammation at the site. That’s important to know because acetaminophen will help reduce pain and fever. But ibuprofen, naproxen and aspirin will do that plus reduce inflammation and swelling.

What potential side effects do NSAIDs have?

All drugs, including NSAIDs, come with a risk of side effects. NSAIDs can irritate the lining of your stomach, so if you have a delicate stomach, talk to your provider before taking. And you shouldn’t take any OTC pain reliever often and over a long period of time without first discussing with your doctor.

Ibuprofen very rarely causes side effects. In the less than 1% of instances where it does, they might include drowsiness, abdominal pain, diarrhea and constipation.

NSAIDs are not recommended for people with aspirin-sensitive asthma. Check with your asthma specialist to find out what alternatives are available.

What are Tylenol’s potential side effects?

Like NSAIDs, Tylenol might also cause a rash, stomach upset or even headache – one of the very conditions it’s used to treat.

But there are more serious side effects, too – liver damage, for instance.

Thanks. Now, about those warnings you mentioned – what are some?

Some people need to be cautious about taking OTC pain relievers. People with these conditions should talk to their doctor or other clinician about which pain reliever is safest for them:

  • Diabetes
  • Hypertension
  • High cholesterol
  • Bleeding disorders
  • History of gastric ulcers
  • History of blood clots
  • Cardiac conditions

People on certain types of chemotherapy and oral antifungal medications need to have their liver function monitored while on those medications. You wouldn’t want to take large doses of Tylenol and one of those medications at the same time.

Antifungals are very common. They’re used to treat conditions ranging from mildly irritating (yeast infections of the skin) to severe (meningitis and certain infections of the eye, blood, lungs and sinuses).

I want to add that patients should keep up with all the medications they take – including supplements – and why they need each one. But it can’t be only up to patients. Clinicians need to be proactive about asking what over-the-counter medicines and supplements their patients are taking and about educating patients on the potential risks of taking any OTC medication if they have certain conditions.

When should you take aspirin or another NSAID?

In general, they’re good for pain associated with:

  • inflammatory conditions, such as arthritis
  • orthopedic conditions
  • premenstrual or period cramps
  • mild to moderate headaches

When should you take Tylenol?

Tylenol is also effective at reducing aches, pains and fevers, but as we’ve discussed, it doesn’t treat inflammation.

The question isn’t so much about when to take one kind or the other. It’s more about who should take each kind of pain reliever. Tylenol is often a safer choice for people with stomach issues, kidney disease or who are already on aspirin therapy for their heart.

Any warnings people need to keep in mind about NSAIDs? What pre-existing conditions might make them risky?

When taken for 10 days or less, NSAIDs are safe for most people, although stomach irritation and even ulcers are possible for some people who take NSAIDs long-term.

If you’re on certain medicines – blood thinners like Coumadin, Plavix, Eliquis, Xarelto – talk to your doctor or pharmacist before taking an OTC NSAID. That also goes for people with high blood pressure; heart, kidney or liver disease; or bleeding in their stomach or digestive tract.

Children younger than 18 years should not take aspirin due to a small risk for Reye’s syndrome, a rare condition characterized by sudden, acute brain damage and liver problems. While uncommon, it can occur when aspirin is given to children for viral infections, such as chickenpox or the flu.

How long does it usually take for OTC pain relievers to work?

If you haven’t gotten any relief in an hour, it’s OK to take another pain reliever. But try a different one. If you took ibuprofen and it’s not working, try Tylenol. And if you took Tylenol first, try Advil or something similar.

It’s best to wait four to six hours between doses. And always read the label to see what the maximum recommended dose is, and don’t exceed it.

When should you contact a health care clinician about pain?

If you’ve taken an OTC pain reliever for multiple days in a row and still haven’t gotten relief, contact your doctor. And if pain is interfering with your daily life – let’s say you’re having a hard time walking because your ankle hurts – contact your primary care clinician.