Why do my sore throat and cough worsen at night?

Why Sore Throat and Cough Worsen at Night

Your nighttime worsening of sore throat and cough is primarily due to physiological changes that occur during sleep, including postural effects on mucus drainage, reduced swallowing frequency allowing throat irritation to accumulate, and the natural circadian rhythm of airway inflammation that peaks in the early morning hours. 1

Physiological Mechanisms Behind Nighttime Worsening

Airway Inflammation and Circadian Rhythms

• Airway inflammation and obstruction naturally peak at 4:00 AM, with nighttime lung function (PEF and FEV1) reduced compared to daytime values, particularly if you have underlying asthma or reactive airways. 1
• This circadian pattern affects 74% of asthma patients who experience nocturnal symptoms leading to awakening at least once weekly. 1
• Up to 80% of fatal asthma attacks occur overnight or early morning, making nocturnal symptoms a critical marker if asthma is the underlying cause. 1

Postural and Mechanical Factors

• When lying flat, mucus and secretions pool in the throat rather than draining naturally as they do when upright, leading to increased throat irritation and triggering the cough reflex. 1
• Reduced swallowing frequency during sleep allows irritants to remain in contact with throat tissues longer, intensifying soreness. 2
• Mouth breathing during sleep (especially with nasal congestion) dries the throat mucosa, worsening pain and irritation. 2

Common Underlying Causes to Consider

Gastroesophageal Reflux Disease (GERD)

• GERD commonly causes nocturnal cough and sore throat in both children and adults, as stomach acid more easily reaches the throat when lying flat. 1
• The American Gastroenterological Association identifies GERD as a frequent cause of nighttime respiratory symptoms. 1

Asthma or Reactive Airways

• Only one-third of people with isolated nocturnal cough actually have asthma, but it remains an important differential diagnosis. 1
• Look for other asthma symptoms including daytime wheeze, shortness of breath, chest tightness, or exercise limitation. 1

Post-Nasal Drip and Upper Airway Issues

• Increased nocturnal cough has been reported with snoring disorders and sleep-disordered breathing. 3, 1
• However, note that "post-nasal drip" as traditionally described lacks strong scientific validity, particularly in children. 1

Practical Management Approach

Immediate Symptomatic Relief

• For sore throat pain, ibuprofen and naproxen are recommended as first-line symptomatic treatment. 4
• Simple home remedies like honey and lemon may be as effective as pharmacological treatments for benign viral causes. 5

Nighttime-Specific Interventions

• Sedative antihistamines (first-generation) may be particularly suitable for nocturnal cough as they suppress cough and cause drowsiness that aids sleep. 6, 5, 2
• Elevate the head of your bed 6-8 inches to reduce reflux and improve mucus drainage. 1
• Use a humidifier to prevent throat drying from mouth breathing. 2

For Dry, Non-Productive Cough

• Dextromethorphan at 60 mg provides optimal cough suppression, though standard over-the-counter dosing is often subtherapeutic at 30 mg. 6, 5
• Menthol inhalation provides acute but short-lived cough suppression for quick relief. 6, 5
• Avoid codeine, as it has no greater efficacy than dextromethorphan but carries a much greater adverse side effect profile. 6, 5

For Productive Cough

• Do not use cough suppressants like dextromethorphan for productive cough, as they interfere with beneficial clearing of secretions. 6
• Focus on expectorants and adequate hydration instead. 6

Important Caveats

When to Seek Further Evaluation

• If symptoms persist beyond 7-14 days (the typical self-limiting course of viral sore throat). 4, 7
• If you develop red flag symptoms including immunosuppression signs, severe systemic infection, difficulty breathing, or inability to swallow. 4
• If nocturnal symptoms significantly disrupt sleep or daily functioning despite symptomatic treatment. 1

Antibiotic Considerations

• Antibiotics are not routinely indicated for sore throat, as less than 35% of cases are bacterial. 4
• Even when bacterial pharyngitis is present, antibiotics only modestly shorten symptom duration. 4, 8
• Clinical scores (Centor, McIsaac, FeverPAIN) should guide antibiotic decisions if bacterial infection is suspected. 4

Reliability of Nocturnal Symptom Reporting

• Subjective reports of nocturnal cough correlate poorly with objective measurements (Cohen's kappa 0.3), so your perception of worsening may be more pronounced than actual cough frequency. 3, 1
• However, parents' reports do correlate with detection of change in symptoms over time. 3