What's the Best Over-the-Counter Option When You Have a Fever?

Open up your medicine cabinet and you'll likely find several options to bring down a fever. Bottles of pain relievers containing ibuprofen (such as Advil or Motrin) and acetaminophen (Tylenol) are both staples for at-home treatment. But does it matter which fever-fighting over-the-counter (OTC) medication you choose?

We break down the best uses — and safety concerns to keep in mind — of these two readily available types of meds that can help relieve pain and bring down a fever.

Pain relievers containing ibuprofen hit the headlines early in the novel coronavirus pandemic when a March 2020 article in the ​Lancet​ suggested these meds might raise the risk of severe COVID-19 symptoms in people already burdened with hypertension, diabetes or heart disease. Many took this to mean that acetaminophen would be a better alternative for a COVID-19-related fever.

These concerns have gone by the wayside as the world learns more about COVID-19.

"What is fortunate is that there has been no association established that proves that ibuprofen worsens COVID-19," says Mike Sevilla, MD, a practicing family physician in Salem, Ohio.

Using non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, is not associated with more severe outcomes for people with COVID-19, per a September 2020 study published in ​PLOS Medicine​. The study examined more than 9,000 Danish people diagnosed with SARS-CoV-2 (the virus that causes COVID-19) and found that taking NSAIDs didn't increase the rate of hospitalization, admission to the intensive care unit or mortality.

Some moderately ill COVID-19 patients are treated with intravenous NSAIDs like ibuprofen, says Len Horovitz, MD, a pulmonary specialist with Lenox Hill Hospital in New York City.

No one knows exactly how acetaminophen works, but one of the current theories is that it blocks chemicals called prostaglandins to reduce pain and discomfort, Dr. Sevilla says. Prostaglandins can contribute to fever and to aches and pains. It is not an NSAID and therefore doesn't help reduce inflammation.

"This is a favorite for fevers and headaches," says Hugh Snyder, MD, a family medicine physician at Summit Springfield Family Medicine, part of Atlantic Health System, in New Jersey. "It isn't as effective at reducing inflammation from musculoskeletal injuries like sprains or strains."

But it can sometimes help treat pain from arthritis, according to Penn Medicine. Acetaminophen will relieve pain and/or fever for 4 to 6 hours, per Penn Medicine.

There are several advantages to using acetaminophen over ibuprofen. For one thing, it can be given a little earlier in life, says Diana Graalum, PharmD, clinical pharmacy manager at MedSavvy, a web-based service that evaluates treatment options for consumers.

Acetaminophen can be used in children under the age of 6 months, according to UnityPoint Health.

It can be used right up to the point of surgery for children, says the Hospital for Special Surgery (HSS). That's true for adults, too, and this OTC med is also safe for pregnant women.

Acetaminophen and ibuprofen have very different safety profiles, based on how these meds work in the body.

"Acetaminophen works in the liver and therefore can cause liver damage when taking more than 4,000 milligrams (mg) per day," says Rupal Mansukhani, PharmD, a clinical pharmacist with Morristown Medical Center in New Jersey. It can also cause liver failure if more than the recommended dose is taken a single time. "Patients with active and severe [liver] disease or severe [liver] impairment should avoid using acetaminophen."

People who drink excessive alcohol should avoid acetaminophen as well, Dr. Sevilla advises.

Acetaminophen can also interact with blood thinners as well as certain seizure and other medications. "For specific drugs, patients should be checking with their family physician's office," Dr. Sevilla says.

Like acetaminophen, ibuprofen also acts on the prostaglandins, which tell your brain to feel pain, according to Johns Hopkins Medicine.

But it works through a slightly different mechanism, says Sandra Kemmerly, MD, system medical director of hospital quality at Ochsner Health, in New Orleans. Because ibuprofen is an NSAID, it can reduce not just pain and fever but also inflammation. This is one of the things that makes it different from acetaminophen. Aspirin and naproxen (Aleve) are also NSAIDs.

Ibuprofen is best used for fever, headaches, back pain, menstrual cramps, toothaches, arthritis, minor injuries and inflammation, per Penn Medicine.

The main benefit of ibuprofen over acetaminophen is that it can quell inflammation.

"Simply put, these are great anti-inflammatory drugs that aren't steroids or aspirin," Dr. Snyder says. (Both steroids and aspirin can have serious side effects). "This class of analgesics [pain relievers] will reduce pain and fever by reducing the body's inflammatory response," he adds.

Motrin and Advil generally contain 200 to 400 mg of ibuprofen. The maximum recommended dose is 1,200 mg a day, according to Penn Medicine. Like acetaminophen, the effects usually last for 4 to 6 hours.

Ibuprofen should only be given to children over the age of 6 months, per UnityPoint. And it should not be used within 72 hours before surgery. It's also not safe for women who are pregnant or trying to get pregnant. Like acetaminophen, ibuprofen can interact with alcohol and blood thinners along with certain blood pressure medications, such as lisinopril.

Gastrointestinal effects are more common with ibuprofen.

Taking ibuprofen "can put you at a risk for stomach bleeds or pains if used in high doses," Mansukhani says. If you have a history of stomach ulcers, GI bleeding or heart disease, stay away from this pain reliever and fever reducer, Dr. Sevilla says.

"There are no head-to-head comparisons to say one is better than the other" at reducing fevers, Dr. Kemmerly says. That includes for COVID-19 symptoms. Both acetaminophen and ibuprofen are available in tablets, capsules, solutions, melts and chewables and are easy to use, Mansukhani adds.

Ibuprofen, of course, is better if you have any kind of inflammation like rheumatoid arthritis, osteoarthritis or migraines. But it comes with more side effects.

"Some physicians will just go ahead and start with acetaminophen because of the lower risk of side effects," says Sherri Willard-Argyres, PharmD, a clinical pharmacist with MedSavvy.

Ultimately, personal preference, along with what works best with your symptoms, can drive your decision.

You can also alternate acetaminophen and ibuprofen, as long as you don't fall into a group that shouldn't use one or the other. "What we do sometimes with unrelenting temperatures, because each drug works on different receptors, is alternate for short periods of time, 24 to 48 hours max," Dr. Kemmerly says.