What are the recommended pain medications for a painful cough?

Pain Medication for Painful Coughing

For painful cough, dextromethorphan is the recommended first-line medication due to its efficacy in suppressing cough with a better safety profile than opioid alternatives. 1

First-Line Treatments

Non-Pharmacological Options

• Simple home remedies like honey and lemon can provide symptomatic relief 1
• Voluntary cough suppression techniques may help reduce cough frequency 1

First-Line Pharmacological Options

1. Dextromethorphan

   • Non-sedating opiate derivative with proven efficacy in suppressing acute cough 1
   • Optimal dosing: 60 mg provides maximum and prolonged cough reflex suppression 1
   • Available in many over-the-counter preparations
   • Caution: Check for other ingredients like paracetamol in combined preparations 1

2. Menthol

   • Can be used as inhalation therapy for acute cough suppression 1
   • Available as menthol crystals or proprietary capsules
   • Effect is short-lived but immediate 1

3. Sedative antihistamines

   • First-generation antihistamines with sedative properties can suppress cough 1
   • Particularly useful for nocturnal cough when drowsiness is beneficial 1

Second-Line Treatments (For Persistent Painful Cough)

When first-line treatments are ineffective, especially in severe or persistent painful cough:

1. Opioid derivatives (when dextromethorphan is ineffective):

   • Pholcodine or hydrocodone (where available) 1
   • Dihydrocodeine or morphine for more severe cases 1
   • Codeine is less preferred due to greater side effect profile 1

   Typical dosing:

   • Codeine: 30-60 mg four times daily 1
   • Pholcodine: 10 mL four times daily 1
   • Morphine: 5-10 mg slow-release twice daily 1

2. Peripherally-acting antitussives (for opioid-resistant cough):

   • Levodropropizine (75 mg three times daily) 1
   • Moguisteine (100-200 mg three times daily) 1

Special Considerations

Cautions with Opioid Antitussives

• Codeine and pholcodine have no greater efficacy than dextromethorphan but have a much greater adverse side effect profile 1
• Side effects include drowsiness, nausea, constipation, and potential for physical dependence 2
• Not recommended as first-line therapy due to adverse effects 1

For Nocturnal Painful Cough

• First-generation antihistamines may be particularly useful due to their sedative properties 1
• A bedtime dose of dextromethorphan or menthol can help suppress cough during sleep 1

For Intractable Painful Cough

• Local anesthetics like nebulized lidocaine (5 mL of 0.2% three times daily) may be considered when other approaches fail 1
• Caution: Assess aspiration risk before using local anesthetics 1

Algorithm for Managing Painful Cough

1. Start with simple home remedies (honey and lemon) and voluntary cough suppression
2. If insufficient relief, add dextromethorphan (optimal dose 60 mg)
3. For nocturnal cough, consider adding a sedative antihistamine
4. For persistent painful cough despite above measures, consider opioid derivatives (preferably pholcodine or hydrocodone where available)
5. For refractory cases, consider peripherally-acting antitussives or local anesthetics

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (many OTC preparations contain lower doses than the optimal 60 mg) 1
• Defaulting to codeine as first-line therapy despite its poorer side effect profile compared to dextromethorphan 1
• Failing to address the underlying cause of the cough while providing symptomatic relief
• Using local anesthetics in patients with high aspiration risk 1