Management of the Common Cold
Primary Recommendation
The common cold is a self-limiting viral illness requiring only symptomatic management—antibiotics are never indicated and combination antihistamine-decongestant-analgesic products provide the most effective symptom relief, with approximately 1 in 4 patients experiencing significant improvement. 1, 2
Initial Assessment and Red Flags
When evaluating a patient with cold symptoms, rule out the following warning signs that require further investigation or specialist referral:
- Hemoptysis (any amount warrants chest radiograph and possible bronchoscopy) 3
- Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement 4, 1
- Severe unilateral facial pain suggesting bacterial sinusitis 4
- "Double sickening" pattern (initial improvement followed by worsening) 4
- Acute breathlessness requiring assessment for asthma or anaphylaxis 3
- Suspected foreign body inhalation (mandatory bronchoscopy referral) 3
Common pitfall: Do not diagnose bacterial sinusitis in the first 10 days of symptoms—87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics. 3
Symptomatic Treatment Algorithm
For Adults with Multiple Symptoms (First-Line)
Use combination antihistamine-decongestant-analgesic products as they provide superior relief compared to single agents, with an odds ratio of treatment failure of 0.47 (95% CI 0.33-0.67; NNTB 5.6). 2, 5
- Specific effective combination: First-generation antihistamine (brompheniramine) + sustained-release pseudoephedrine reduces congestion and rhinorrhea 1
- Dosing strategy: Two tablets at first dose is more effective than one tablet 6
- Timing matters: Starting treatment within the first 2 days of symptom onset provides greatest efficacy 6
For Targeted Single Symptoms
Nasal Congestion
- Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit 2, 7
- Topical nasal decongestants are effective but limit use to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 1, 2
Rhinorrhea (Runny Nose)
- Ipratropium bromide nasal spray effectively reduces rhinorrhea but does not improve nasal congestion 2, 7
- May cause minor side effects like nasal dryness 2
Pain, Headache, Malaise
- NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing 1, 2
- Acetaminophen/paracetamol may help nasal obstruction and rhinorrhea but does not improve other symptoms 2
Cough
- Dextromethorphan (60 mg for maximum effect) suppresses acute cough, though standard OTC doses are likely subtherapeutic 3, 8
- Menthol inhalation provides acute but short-lived cough suppression 3
- Honey and lemon is recommended as a simple, inexpensive home remedy with patient-reported benefit 3
- Avoid opiate antitussives due to significant adverse effects without clear superiority 3
Evidence-Based Adjunctive Therapies
Zinc Supplementation
Zinc lozenges (≥75 mg/day) significantly reduce cold duration BUT only if started within 24 hours of symptom onset. 1, 2, 7
- Use zinc acetate or zinc gluconate formulations 1
- Critical timing: No benefit if symptoms already established beyond 24 hours 4, 2
- Potential side effects include bad taste and nausea 2
Nasal Saline Irrigation
- Provides modest symptom relief, particularly beneficial in children 2, 7
- Helps dilute secretions and facilitate elimination 1
Vitamin C
- Prophylactic use modestly reduces symptom duration in adults and children 7
- May be worth trying given low cost and safety profile 2
Pediatric-Specific Management
Critical warning: Over-the-counter cough and cold medications should NOT be used in children younger than 4 years due to potential harm without benefit. 7, 9
Safe and Effective Treatments for Children
- Honey (for children ≥1 year old) 1, 9
- Acetylcysteine 9
- Nasal saline irrigation 1, 9
- Intranasal ipratropium 9
- Topical vapor rub (camphor, menthol, eucalyptus oils) 7, 9
- Acetaminophen/paracetamol for fever and pain 1
What Does NOT Work (Avoid These)
Never Prescribe
- Antibiotics have no benefit for uncomplicated common cold and contribute to antimicrobial resistance 4, 1, 2, 7
- Antibiotics do not prevent bacterial complications 1
Ineffective Treatments
- Intranasal corticosteroids for acute cold symptoms 2, 7
- Oral corticosteroids (prednisolone) 7
- Non-sedating antihistamines (newer generation) are ineffective 3
- Echinacea angustifolia preparations 7
- Steam/heated humidified air 2
- Codeine for cough in adults 7
When Symptoms Persist Beyond 10 Days
Approximately 25% of patients continue with cough and nasal discharge up to 14 days—this is normal and does not indicate bacterial infection. 3, 4, 1
Post-Viral Rhinosinusitis Management
- Symptoms persisting >10 days without improvement classify as post-viral rhinosinusitis 4
- Consider intranasal corticosteroids for post-viral symptoms 4
- Continue symptomatic treatment with combination products 4
Bacterial Rhinosinusitis Criteria
Only suspect bacterial infection if at least 3 of 5 criteria are present:
- Discolored (purulent) nasal discharge
- Severe local pain
- Fever >38°C (100.4°F)
- "Double sickening" pattern
- Elevated inflammatory markers 4
Key point: Only 0.5-2% of viral URIs develop bacterial complications. 4
Patient Education and Prevention
Set Realistic Expectations
- Cold symptoms typically last 7-10 days 1, 2
- Up to 25% may have symptoms for 14 days 4, 1
- The illness is self-limiting and viral—antibiotics will not help 1
Prevention Strategies
- Hand hygiene is the most effective prevention method 7, 9
- Prophylactic probiotics (Lactobacillus casei in older adults) may reduce cold incidence 9
- Prophylactic vitamin C modestly reduces symptom duration 7
- Garlic may decrease frequency but not duration 7
Adverse Effects to Monitor
- Combination products: 31% experience adverse effects vs 13% with placebo (OR 1.58) 5
- Decongestant-analgesic combinations: NNTH of 17 for adverse effects 5
- Most common: drowsiness, hypersomnia with antihistamines 5
Special Populations
Pregnant Women
- Acetaminophen/paracetamol is first-line for pain and fever 1