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Why High Blood Pressure and Pain Relievers Don’t Always Mix

Adults with hypertension should talk with their doctor before popping a pain pill, new research suggests

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If you didn’t know better, you might think over-the-counter pain relievers are risk-free. After all, they’re available without any sort of permission or prescription from a health care provider. But it turns out, they come with plenty of risks — especially for people with high blood pressure.

The American Heart Association (AHA) has long recommended acetaminophen (Tylenol) as a safe alternative to nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) and naproxen (Aleve). Research shows that NSAIDs can raise blood pressure; and if you already have high blood pressure, they can make it worse. They can also prevent a number of common blood pressure meds like ACE inhibitors and diuretics from doing their job.

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However, mounting research, most notably a study published in February in Circulation, suggests that acetaminophen isn’t without blood-pressure pitfalls if taken regularly. Researchers enlisted 110 people with high blood pressure and randomly gave the maximum recommended daily dose of acetaminophen (4 grams) to some of the participants and a placebo to the others every day for two weeks. Then they gave the placebo group daily acetaminophen and the acetaminophen group a placebo for two weeks. At the end of the study, the researchers found that taking acetaminophen on a regular basis increased the systolic blood pressure (the number on the top) by about 5 mmHg (millimeters of mercury — a measurement of pressure) in people with hypertension. What’s more, the effect was similar to that of NSAIDs, the authors note.

“The thing that struck me is that this happened over a short time period,” says Steven M. Smith, an epidemiologist focused on medications in the Department of Pharmacotherapy and Translational Research at the University of Florida College of Pharmacy, who was not involved in the study. “There are lots of us who use Tylenol for aches and pains on a not-infrequent basis, but [this study shows] it doesn’t take much to experience an increase in blood pressure. That sort of increase, especially if it’s sustained, puts us at risk for adverse consequences in terms of strokes, heart attacks and death.” 

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High blood pressure is the number one preventable cause of heart disease and stroke in the U.S., according to the AHA, and it is second on the list of preventable causes of death for any reason, right behind smoking. Nearly half of U.S. adults (47 percent, or 116 million) have high blood pressure, the Centers for Disease Control and Prevention (CDC) reports.

Early warnings

Acetaminophen became the pain reliever of choice for people with high blood pressure and/or heart disease almost by default. In 2004, the Food and Drug Administration (FDA) began taking a closer look at NSAIDs after the prescription painkiller rofecoxib (Vioxx) was voluntarily taken off the market in the wake of evidence showing the drug increased the risk of heart attacks and strokes. In taking a closer look at other NSAIDs — both prescription and over-the-counter non-aspirin NSAIDs — the FDA found sufficient evidence to mandate a warning about the risk on all NSAID labels.

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Acetaminophen, meanwhile, was largely deemed a safer alternative, even as studies began to question the effect of the analgesic on blood pressure. A number of reports “have suggested that Tylenol increases blood pressure and may increase the risk of developing high blood pressure, but these studies were pushed to the side because there were limitations to the studies,” says Smith, whose research is focused on medication outcomes in people with hypertension. The recent report in Circulation, however, “is the most rigorous study to date on this topic,” he says.

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Talk with your doctor about best options

What, then, is the safest pain medication? That’s a question anyone with high blood pressure, heart disease or for that matter kidney disease should ask their health care provider, says cardiologist Donald Lloyd-Jones, M.D., chair of the Department of Preventive Medicine at Northwestern University Feinberg School of Medicine and president of the AHA. And yet, research suggests these conversations aren’t taking place.

Nearly half of adults in the U.S. have high blood pressure and only 53 percent of those who take over-the-counter pain relievers check with their doctor before taking them, according to a 2021 survey commissioned by the AHA.

“For a long time, NSAIDs have been recognized as being problematic in patients with heart failure, hypertension and kidney disease,” Smith says. “With acetaminophen, there’s the same problematic effect with blood pressure, yet we don’t recognize that as being a problem.”

But that doesn’t necessarily mean acetaminophen is off-limits, especially if you take it only on occasion. “The risks of using acetaminophen for fever or aches and pains every once in a while — even for people who have hypertension — are quite low,” Smith adds. “The real issue is for people who are taking it every day.”

However, he warns against taking effervescent acetaminophen, citing research just published in European Heart Journal. The fizzy, dissolvable tablets are high in sodium and are associated with a greater risk of cardiovascular disease in people with and without high blood pressure. 

“There are other considerations as well,” Lloyd-Jones says. “Unlike acetaminophen, most of the NSAIDs compete directly with aspirin, so people who need aspirin because they’ve had a heart attack, stroke or a stent procedure should be careful not to lose the protection they are getting from aspirin by taking one of these other medications. This is much less of a concern with acetaminophen. NSAIDs are also much more likely to cause stomach bleeding than acetaminophen.”

Bottom line: Talk with your doctor about what makes sense for you. As Lloyd-Jones points out, age, as well as pain itself, can also raise blood pressure, so it’s “important to find the right balance,” he says. “Whatever medication is used, people with high blood pressure should be monitoring it at home regularly, and especially doing so and reporting back to their doctor whenever they start any new medication.”

Kimberly Goad is a New York–based journalist who has covered health for some of the nation’s top consumer publications. Her work has appeared in Women’s Health, Men’s Health and Reader’s Digest.

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