A few thoughts, with the caveat that I can't tell from a distance whether the toe is simply healing slowly or whether there is another issue contributing to the persistent swelling and pain.
For a painful fractured toe, ibuprofen often works better than acetaminophen because it reduces inflammation as well as pain. Acetaminophen is primarily a pain reliever and fever reducer. The fact that neither seems to affect the swelling is not particularly surprising if the swelling is being driven by the injury itself.
Regarding kidneys, the concern is mainly with the ibuprofen and other NSAIDs. In healthy younger people, occasional use is usually not a major issue. In older adults, especially those with high blood pressure, reduced kidney reserve, heart disease, dehydration, or certain medications, chronic NSAID use deserves more caution. Since you are an octogenarian and have been on blood-pressure medication for many years, it would be reasonable to keep an eye on kidney function periodically if you are taking ibuprofen regularly.
As for Pregabalin, it is a somewhat different animal. It tends to work best for nerve-related pain—burning, shooting, tingling, electric-shock sensations, diabetic neuropathy, post-herpetic neuralgia, and the like. A broken toe produces mostly nociceptive pain from injured bone and soft tissue. Pregabalin is therefore not the first drug most physicians would think of for a routine toe fracture.
That said, some people do find it helpful for chronic pain that is disrupting sleep, and 75 mg is a common starting dose. The potential advantage is that it is generally not hard on the kidneys in the same way NSAIDs are, though the dose often needs adjustment if kidney function is reduced. The main side effects I would worry about in your case are:
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Drowsiness the next morning.
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Dizziness.
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Impaired balance and increased fall risk.
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Occasionally blurred vision or a "foggy" feeling.
Knowing that you have a tendency to fall and have installed grab bars around your home, that balance issue is the part that would make me pause. Many older adults tolerate pregabalin perfectly well; others become noticeably unsteady.
One thing that catches my attention is not the medication choice but the phrase "constant swelling mainly in the foot area where it connects." If this fracture is not recent and you are still having persistent swelling and throbbing around the metatarsophalangeal joint (where the toe joins the foot), it may be worth asking whether the toe has been re-examined. Sometimes there can be a more significant injury around the joint, delayed healing, arthritis triggered by the injury, or another process entirely.
How long ago was the fracture, and was it confirmed by X-ray? That would help put the persistent swelling into context.
Twenty years changes the picture completely.
At that point, you are no longer dealing with a healing fracture. You are dealing with the long-term consequences of an old injury. The persistent swelling where the toe joins the foot suggests there may be chronic joint damage, deformity, post-traumatic arthritis, malunion of the fracture, or some combination of these.
The fact that local doctors look at it and immediately say, "That must be painful," without proposing much treatment makes me suspect the toe may be visibly abnormal and that they regard the underlying structural problem as not readily fixable. Whether that assessment is correct is another matter.
In that situation, ibuprofen, acetaminophen, and pregabalin are addressing symptoms rather than the cause.
As for pregabalin specifically, I would not expect dramatic results if the pain is primarily arthritic or mechanical. If the pain has characteristics such as burning, stabbing, tingling, electric-shock sensations, or hypersensitivity to touch, then pregabalin becomes more plausible. If instead it is a deep throbbing ache that worsens with walking or pressure on the foot, I would not expect pregabalin to outperform ibuprofen.
One thing worth considering is whether anyone has obtained an X-ray in recent years. A modern film might reveal whether there is severe arthritis in the metatarsophalangeal joint, an old deformity, or something else. Twenty years ago, a doctor seeing an acute fracture and recommending aspirin was perfectly reasonable. Twenty years later, the question is different: "What is the foot like now?"
From a medication standpoint, if the choice is between occasional bedtime ibuprofen and adding pregabalin, I would be inclined to judge them on the basis of side effects and effectiveness rather than kidney fears alone. At standard doses, many people your age take ibuprofen intermittently for years without obvious kidney injury, although monitoring kidney function is sensible. Pregabalin avoids the NSAID kidney issue but introduces the possibility of sedation, dizziness, and increased fall risk—which, given your history of falls, is not a trivial trade-off.
One practical approach, if your physician agrees, would be a cautious trial of 75 mg pregabalin in the evening on a night when you do not have to be up and moving early the next morning. You would learn fairly quickly whether it helps the pain and whether it makes you feel unsteady or groggy. Some people know after one or two doses that it is not for them; others find it unexpectedly useful.
Out of curiosity, has the pain been essentially stable for twenty years, or has it been gradually getting worse? Progressive worsening would make post-traumatic arthritis particularly likely.
That is exactly the comparison I would be making.
In someone who is still working, driving daily, climbing ladders, and operating machinery, a medication that causes even mild drowsiness can be a substantial problem. In your circumstances, the calculation is different. If inadequate sleep leaves you tired every day, and a medication lets you sleep through the night with only mild morning grogginess, that may be a favorable trade.
The fact that the toe doesn't hurt when you're upright but throbs in bed is interesting. When you lie down, blood flow and tissue fluid distribution change. Many people with arthritis or old injuries notice that an area becomes more noticeable at night when there are fewer distractions and when inflammatory changes around the joint are more apparent. It doesn't particularly sound like nerve pain to me, though I certainly can't rule it out.
One practical advantage of pregabalin in your case is that you would be using it largely for a nighttime symptom. If it makes you somewhat sleepy, that is not necessarily an unwanted effect. The question is what happens the next morning. Some people wake up clear-headed; others feel as though they have cotton wool between their ears until noon.
The other factor is falls. You have told me before that falling is a real concern and that you've installed grab bars extensively. Poor sleep itself increases fall risk. So does pregabalin. The question is which effect is larger for you. Unfortunately, that is difficult to predict from theory alone.
If your physician is comfortable with it, a short trial seems reasonable. After several nights you would likely know:
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Does it reduce the throbbing?
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Does it improve sleep quality?
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Do you feel steadier or less steady the next day than you do after a bad night?
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Does it produce any unpleasant mental fog?
One thing I would be tempted to try before adding medication, if you haven't already, is a little experimentation with foot position in bed. Some people with old foot injuries find that slight elevation, a pillow arrangement, or even keeping bedclothes from pressing on the toe changes the nighttime pain considerably. After twenty years you've probably explored most of that territory, but occasionally a mechanical solution turns out to help more than expected.
From what you've described, my biggest concern is not kidney damage from occasional box-dose ibuprofen. It is whether pregabalin, if it helps, helps enough to outweigh any effect on balance. Given your freedom to sleep in and take life at your own pace, the threshold for accepting a little morning drowsiness is certainly lower than it would be for someone rushing off to work at 7 a.m. every day. The only way to know where you personally fall on that spectrum is usually a cautious trial.
That does shift the balance somewhat.
You have described a living arrangement that is unusually forgiving of minor impairment: grab bars, soft landing zones, people nearby, a call buzzer, and no obligation to rush out the door or perform demanding tasks. Those are exactly the factors a physician would consider when weighing the risks of a sedating medication.
The remaining question is how you react to pregabalin. People vary enormously. Some take 75 mg and barely notice it. Others feel distinctly woozy. Age increases the odds of side effects, but it doesn't determine them.
One thing I would pay attention to is when you wake up. You mentioned that once awake, you simply get up. If pregabalin works for you, the ideal outcome is that it reduces the toe's throbbing and lets you sleep longer, after which you wake feeling reasonably normal. The less desirable outcome is that you wake at the usual hour anyway but feel unsteady because the medication is still active.
Given your circumstances, I would be more concerned about cognitive fog than drowsiness itself. Drowsiness can be a nuisance; confusion, poor judgment, or altered balance are what lead to trouble. If you try it, the first few mornings are the ones I'd watch most closely.
There is also a possibility that it simply does nothing useful. Since your pain sounds mechanical and positional rather than obviously neuropathic, I would not be shocked if you took pregabalin for several nights and concluded, "Well, that was interesting, but the toe still throbs."
On the other hand, sleep deprivation has its own costs. A medication that cuts the pain enough to allow solid sleep can sometimes produce a net improvement in alertness despite being mildly sedating. I've seen that paradox often enough: a person takes a sedating medication at night and is actually sharper the next day because they finally slept.
Your description of the precautions "verging on the ridiculous" made me smile. From your earlier descriptions, I had already formed the impression that Pok and the others have decided that allowing you to fall is not an acceptable outcome and have therefore engineered the environment accordingly. In that setting, a carefully monitored trial of a bedtime medication sounds considerably less risky than it would for an older person living alone in an ordinary house.
That is actually a useful clue.
By letting the foot hang a few inches off the edge of the mattress with no covers touching it, you have already eliminated two common aggravating factors: pressure from bedding and direct contact with the mattress. People with painful toes or forefoot arthritis often discover exactly that arrangement on their own.
The fact that it still throbs despite those accommodations suggests the pain is coming from the joint or surrounding tissues themselves rather than from external pressure. In other words, you've already performed one of the obvious experiments, and the result was "still hurts."
The pattern you describe—little or no pain when upright, but throbbing once you settle into bed—reminds me more of chronic inflammatory or arthritic pain than of a nerve problem. That's not a diagnosis, just an observation. It would also help explain why ibuprofen is more effective than acetaminophen: ibuprofen has anti-inflammatory action, while acetaminophen does not.
One question I would be curious about: if you get up and walk around for a few minutes after the throbbing starts, does it improve temporarily when you return to bed? If so, that would further support a circulatory or inflammatory explanation rather than a neuropathic one.
Given everything you've told me, I would not go into a pregabalin trial expecting a dramatic result. I would think of it as an experiment. The possibilities are:
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It helps the pain enough to improve sleep.
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It doesn't help the pain but makes you sleepy.
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It does neither.
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Less likely, it helps substantially because there is a nerve-pain component that isn't obvious from the symptoms.
After twenty years, you know this toe better than any physician seeing it for ten minutes. The strongest evidence so far is that ibuprofen helps and pressure avoidance helps somewhat. Both of those point more toward a local mechanical/inflammatory problem than toward a classic nerve-pain syndrome.
And I must admit I admire the image: an old war-wound of a toe, suspended off the edge of the mattress every night like a delicate artifact that has negotiated its own special sleeping arrangements with the rest of the body. After twenty years, it seems the toe has won that negotiation.
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