Painkillers Explained: Paracetamol, Ibuprofen, Diclofenac and Tramadol Safely

Paracetamol or ibuprofen? Brufen or Voltral? Panadol Extra or Panadol CF? The pain aisle is full of names, and most people choose by habit or a neighbour’s advice. Painkillers are among the most widely used medicines, and also among the most misused, with stomach bleeding, kidney damage and liver injury all being preventable harms. Picking the right one for the right pain, for the shortest time, makes a big difference.

This guide explains the main painkiller groups, how they differ, which one suits which type of pain, who should avoid them, the dangers of combining products, and when pain needs a doctor and not another tablet.

The main groups

1. Paracetamol (acetaminophen)

Paracetamol reduces pain and fever, but has little effect on inflammation. It is gentle on the stomach, and is generally the safest first choice for headaches, mild to moderate pain, fever, toothache and pain in pregnancy. Brands: Panadol 500, Disprol, syrups such as Panadol Syrup and Calpol 6+, and drops such as Panadol Oral Drop for babies.

• The danger is overdose. Too much damages the liver, sometimes silently at first, and can be fatal. Never exceed the maximum daily amount on the pack, and leave the recommended gap between doses.
• Many cold, flu and pain products already contain paracetamol, including Panadol CF, Panadol Extra (with caffeine), Flueze and tramadol combinations. Taking two together doubles the dose without you realising. Always read the ingredient list.
• Take extra care with regular alcohol use, liver disease, low body weight and poor nutrition.
• For children, use the product and measuring device made for their age and weight.

2. NSAIDs (non-steroidal anti-inflammatory drugs)

Ibuprofen (Brufen 400), naproxen, diclofenac, mefenamic acid, and the COX-2 types such as etoricoxib (Starcox 60) reduce pain, swelling and fever. They are useful for muscle and joint pain, sprains, period pain, toothache and arthritis flares.

• Stomach: irritation, ulcers and bleeding. Take with food, use the lowest dose for the shortest time, and never on an empty stomach. Ask about a stomach-protecting medicine if you need them regularly. Read our guide to acidity medicines.
• Kidneys: they can damage the kidneys, especially with dehydration, diabetes, older age, or when combined with water tablets and BP medicines.
• Blood pressure and heart: they can raise blood pressure, worsen heart failure, and raise the risk of heart attack and stroke with long use or high doses.
• Asthma: they can trigger attacks in some people.
• Bleeding: avoid with blood thinners. See our guide to blood thinners.
• Pregnancy: avoid, especially after 28 weeks, unless your doctor says otherwise.
• Do not combine two NSAIDs.

Gels and creams such as Dyclo Emulgel and Brufen Cream deliver the medicine to a painful joint with far less in the blood. They are a good choice for knees, hands and muscles.

3. Nimesulide: be careful

Nimesulide (for example Narcogen) has been linked to liver injury, and has been restricted or withdrawn in several countries. It should not be used in children, in liver disease, or for long periods. Ask your doctor whether a safer option will do.

4. Opioid and opioid-like painkillers

Tramadol (Tramal Plus, Zultracet) and tapentadol (Tapento IR) are used for moderate to severe pain that other medicines do not control, mostly short term, and under a doctor’s supervision. Risks include:

• Drowsiness, dizziness, nausea and constipation.
• Dependence and withdrawal. Never use them for months without review.
• Seizures, particularly at high doses or with antidepressants. See our guide to depression and anxiety medicines.
• Dangerous breathing problems with alcohol, sleeping tablets and sedatives. See insomnia and sleeping tablets.
• Not safe for driving, and not advised in pregnancy or for most children.

5. Nerve pain medicines

Pregabalin and gabapentin are used for burning, shooting nerve pain, such as in diabetes and shingles. They can cause drowsiness, dizziness and swelling, and need to be reduced gradually when stopping.

6. Steroids

Steroid tablets such as prednisolone, including syrups like Neupred, reduce inflammation, but are not painkillers for everyday use. They have many side effects with long courses.

Which painkiller for which pain?

• Headache or fever: paracetamol first. For migraine see migraine medicines.
• Toothache: paracetamol or ibuprofen until you see a dentist. See toothache relief.
• Period pain: an NSAID such as ibuprofen, naproxen or mefenamic acid, taken at the first sign, with food, plus a hot water bottle.
• Sprains, muscle and joint pain: an NSAID gel, or short oral NSAIDs, plus rest, ice and support. See our guides to sprains and joint pain in winter.
• Arthritis: see arthritis medicines.
• Gout flare: NSAIDs or colchicine, not aspirin. See gout.
• Back pain: stay active, with paracetamol or a short NSAID course.
• Children: paracetamol, or ibuprofen if the doctor advises. Never aspirin.
• Pregnancy: paracetamol is usually preferred, but only as needed, at the lowest dose and for the shortest time.

Who should be extra careful?

• People with ulcers, kidney, liver or heart disease, high blood pressure, or asthma.
• Older adults, who are more sensitive to side effects.
• People on blood thinners, steroids, water tablets, ACE inhibitors or ARBs, lithium or methotrexate.
• Pregnant and breastfeeding women.
• Children, who need age-appropriate medicine and measure.

Safe use checklist

• Read the label and the leaflet every time.
• Use the lowest dose that works, for the shortest time.
• Do not combine products with the same ingredient.
• Take NSAIDs with food and a glass of water.
• Store out of reach of children.
• Do not use painkillers daily for headaches or joint pain without medical advice. Frequent use can cause its own headache.

When pain needs a doctor

• Pain that is severe, sudden or getting worse, or lasts more than a week or two despite treatment.
• Chest pain, pain with breathlessness, or severe belly pain. These can be emergencies.
• Pain with fever, swelling, redness, weakness, numbness or after an injury.
• Black stools, vomiting blood or stomach pain after taking painkillers.
• You need painkillers every day.
• You are unsure which painkiller is safe with your conditions.

Frequently asked questions

Is it safe to take Panadol every day?

Short-term, at the recommended amount, it is generally safe. If you need it daily for weeks, see your doctor to find the cause.

Which is stronger, paracetamol or ibuprofen?

They work differently. Ibuprofen is better for inflammatory pain, and paracetamol for general pain and fever. They can be used together, as advised, because they do not interact.

Can I drink alcohol with painkillers?

It is best not to. Alcohol increases the risk of liver injury with paracetamol, and stomach bleeding with NSAIDs.

Why are painkiller injections often given?

They are not usually more effective than tablets, and carry risks of infection and reactions. Ask your doctor if tablets will do.

Order painkillers and pain relief gels from Khasmart, with delivery across Pakistan.

This article is for general information and is not a substitute for advice from your doctor or pharmacist. It does not include doses; always follow the directions on the pack or from your doctor.