Painkillers compared: paracetamol, ibuprofen and codeine

Paracetamol: usually first

Paracetamol is often the first painkiller to try for many everyday aches and pains, and is also used to bring down a high temperature. It is generally gentle on the stomach and suits most people, including many who cannot take anti-inflammatories. The crucial point with paracetamol is to stay within the recommended limit and not to exceed it — taking too much, even a moderate amount above the limit, can seriously harm the liver. Because paracetamol is hidden inside many combination and cold-and-flu remedies, it is easy to double up by accident, so always check labels. Take it as directed, never more than advised, and never combine products that both contain it.

Ibuprofen and other anti-inflammatories: useful but with cautions

Ibuprofen belongs to a group called NSAIDs (non-steroidal anti-inflammatory drugs), which ease pain and reduce inflammation — helpful for things like sprains, period pain, dental pain or arthritis flares. They are effective, but carry more cautions than paracetamol. They can irritate the stomach and cause indigestion or, less commonly, ulcers and bleeding, so they are best taken with or after food. They can also affect the kidneys and, with longer or higher use, the heart, and they may not suit people with certain heart, kidney or stomach conditions. Some people with asthma find NSAIDs trigger symptoms. If you have any of these concerns, check with a pharmacist or doctor before using them regularly.

Codeine: a weak opioid with trade-offs

Codeine is a weak opioid, usually added when paracetamol or an anti-inflammatory alone is not enough, often combined with paracetamol. It can ease moderate pain but brings the typical opioid trade-offs: constipation (very common, so it helps to keep well hydrated and eat fibre), drowsiness, nausea and, with regular or prolonged use, a risk of dependence — so it is meant for short-term use rather than ongoing pain. There is also natural variation in how people's bodies process codeine, so the effect differs from person to person. For these reasons codeine is not given to children, and it should not be used while breastfeeding, as it can be unsafe for the baby. Use it cautiously and only as advised.

The pain ladder idea

Doctors often think about pain relief as a "ladder": start with the simplest, gentlest option and step up only if needed. The lower rungs are non-opioid painkillers such as paracetamol, with an anti-inflammatory like ibuprofen added or used where suitable. If pain is still not controlled, a weak opioid such as codeine can be added for a time, and stronger options are reserved for more severe pain under medical guidance. Sometimes combining a non-opioid with an opioid works better than increasing either alone. The principle is to use the least amount of the gentlest medicine that controls your pain, and to step back down again as the pain settles, rather than staying on stronger painkillers longer than needed.

When to seek help

Painkillers are for managing pain, not a substitute for finding out what is causing it. Seek medical advice if pain is severe, getting worse, lasts longer than you would expect, or keeps coming back; if it stops you sleeping or coping; or if it comes with worrying signs such as fever, unexplained weight loss, weakness, numbness or a severe sudden headache. Get urgent help for chest pain, a sudden severe headache, or signs of a serious allergic reaction to any medicine. If you find yourself needing painkillers most days, or taking more than advised, that is a reason to see your clinician — both to control the pain properly and to avoid the harms of taking too much for too long.