What Over-the-Counter Painkiller is the Best at Killing Pain?

We’ve all had days with nagging headaches, muscle and joint soreness, or general aches and pains, that don’t require medical attention, but require something to take the edge off the pain. That something is often an over-the-counter, or OTC, painkiller. There are a variety of brands, which each have different active ingredients, so which OTC painkillers are the best at decreasing pain?

In general, OTC painkillers can be classified in two categories: non-steroidal anti-inflammatory drugs or NSAIDs and acetaminophen.

Inflammation and fever result from pro-inflammatory chemicals called prostaglandins, and NSAIDs work by decreasing levels of these prostaglandins. The most common OTC variations of NSAIDs include Aspirin which is found in brands like Bufferin and Bayer; Ibuprofen, found in brands like Advil and Motrin; and Naproxen, found in Aleve. NSAIDs are generally safe, but chronic use can irritate the stomach lining and cause ulcers. NSAIDs, are also believed to decrease blood flow through the kidneys which can lead to kidney problems in people with other risk factors for kidney disease. Similarly, while the mechanism isn’t completely clear, NSAIDs, with the exception of Aspirin, can cause cardiovascular damage with extended use. Finally, NSAIDs have been linked to developmental defects in fetuses so it’s generally recommended for pregnant women to avoid NSAIDs, especially late in the pregnancy.

Unlike NSAIDs, it’s unclear how Acetaminophen exactly works, but it’s thought to block enzymes in the brain and spinal cord that produce chemicals that promote pain and fever. One key difference though, is that acetaminophen doesn’t decrease inflammation. It’s found in hundreds of brands like Tylenol, and it’s commonly mixed with other active ingredients as well. Examples include Excedrin which works for migraines and is a mix of acetaminophen, aspirin, and caffeine; and Vicodin, which is a prescription strength painkiller that contains acetaminophen and hydrocodone bitartrate—a type of opiate. Acetaminophen is generally safe to use, but using too much of it can harm the liver, especially if you also drink a lot of alcohol or have existing liver issues.

Now, a common question is “how well do these OTC analgesics work?” To help answer that question, a recent study looked at a number of studies that have been done to compare how different painkillers decreased pain following wisdom teeth removal. Keep in mind that pain varies so it may not be the same for things like migraines, tension headaches, and menstrual cramps. That said, there were some interesting findings. The researchers plotted the number needed to treat, or NNT, for a variety of OTC painkiller combinations. An NNT of one, basically means that you would need to treat one person with the medication for one person to see a benefit. An NNT of 4 means that you would need to treat four people for one person to see a benefit of using the drug. So the lower the NNT the better the medication performed.

So based on the data, ibuprofen in combination with other medications like acetaminophen, performed relatively well. Interestingly, the combination of 200 mg of Ibuprofen with 500 mg of acetaminophen had an NNT of 1.6 which means it worked almost as well as the combination 400 mg of Ibuprofen with 1000 mg of acetaminophen which had an NNT of 1.5. This means you can limit your dose of the medication while maintaining the benefits. Another interesting finding is that both 200 mg and 400 mg doses of fast-acting formulations of ibuprofen alone, which are designed to be quickly absorbed into the bloodstream, and a combination of 200 mg of ibuprofen with 100 mg caffeine all had NNTs of 2.1 giving you more options for relatively effective pain relievers if you’d like to avoid taking acetaminophen. On the other hand, aspirin and acetaminophen by themselves have much higher NNTs meaning that they don’t perform as well.

Alright, as a quick recap … choosing the right over-the-counter painkillers can be confusing. While these drugs are safe at recommended doses taking too much acetaminophen can be hard on the liver, and taking too many NSAIDs can cause stomach, kidney, cardiovascular, and fetal development issues. That said, if there are no reasons to avoid specific medications a combination of 200 mg of Ibuprofen and 500 mg of acetaminophen may be best for temporary pain relief.