What is the treatment for acute cough?

Treatment for Acute Cough

For acute viral cough, start with simple home remedies like honey and lemon, which are as effective as many pharmacological treatments; if additional relief is needed, dextromethorphan at 30-60 mg is the preferred antitussive due to its superior safety profile compared to codeine-based products. 1, 2, 3

Initial Assessment and Red Flags

Before treating acute cough, rule out serious conditions requiring immediate intervention:

• Significant hemoptysis or foreign body aspiration requires urgent specialist referral for bronchoscopy 1
• Acute cough with increasing breathlessness should be assessed for asthma or anaphylaxis 1
• Fever, malaise, purulent sputum, or recent infection history warrants evaluation for pneumonia 1
• Voice changes may indicate vocal cord palsy 1

First-Line Non-Pharmacological Treatment

Simple home remedies are the simplest, cheapest, and often most effective initial approach:

• Honey and lemon mixtures are recommended as first-line treatment 1, 2, 3
• Voluntary cough suppression through central modulation may be sufficient to reduce cough frequency 1, 2, 3
• These approaches work through central modulation of the cough reflex and are particularly appropriate since acute viral cough is almost invariably benign 1

Pharmacological Treatment Options

Dextromethorphan (Preferred Antitussive)

When pharmacological treatment is warranted, dextromethorphan is the recommended first-line agent:

• Dextromethorphan is a non-sedating opiate that effectively suppresses the cough reflex 1, 2, 4, 5
• Maximum cough suppression occurs at 60 mg, which is higher than standard over-the-counter dosing 1, 2, 3
• Standard OTC dosing (typically 15-30 mg) is often subtherapeutic 1, 2, 3
• Meta-analysis demonstrates effectiveness for acute cough 1, 2
• Exercise caution with higher doses as some combination preparations contain paracetamol or other ingredients 1, 2, 3

Menthol Inhalation

For rapid but short-term relief:

• Menthol by inhalation provides acute but short-lived cough suppression 1, 2, 3
• Can be prescribed as menthol crystals BPC or proprietary capsules 1, 2
• Useful for immediate symptom relief but effect does not last 1, 2

Sedative Antihistamines

For nocturnal cough specifically:

• First-generation antihistamines with sedative properties can suppress cough but cause drowsiness 1, 2, 3
• Particularly suitable for nocturnal cough when sleep disruption is the primary concern 1, 2, 3
• Not recommended for daytime use due to sedation 1

Treatments NOT Recommended

Codeine and Pholcodine

These opiate antitussives should be avoided:

• Codeine and pholcodine have no greater efficacy than dextromethorphan 1, 2, 3, 6
• They carry a much greater adverse side effect profile including drowsiness, nausea, constipation, and physical dependence 1, 3
• Studies in acute cough have failed to show beneficial effects for codeine 1, 7

Expectorants, Mucolytics, and Bronchodilators

These agents lack consistent evidence for acute uncomplicated cough:

• Expectorants, mucolytics, antihistamines, and bronchodilators should not be prescribed in acute lower respiratory tract infection in primary care 1
• Consistent evidence for beneficial effects is lacking despite widespread over-the-counter availability 1
• Guaifenesin studies show conflicting results with no clear benefit 8, 7
• Inhaled bronchodilators have not shown relevant beneficial effects in uncomplicated acute cough 1

Practical Treatment Algorithm

1. Start with honey and lemon home remedy 1, 2, 3
2. Encourage voluntary cough suppression techniques 1, 2
3. If additional relief needed during the day: Dextromethorphan 30-60 mg 1, 2, 3, 5
4. If nocturnal cough disrupts sleep: First-generation sedating antihistamine 1, 2, 3
5. For quick temporary relief: Menthol inhalation 1, 2, 3

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (standard OTC dosing may be inadequate) 1, 2, 3
• Prescribing codeine-based products which have no efficacy advantage but increased adverse effects 1, 2, 3
• Suppressing productive cough where clearance of secretions is beneficial 1, 3
• Using expectorants or mucolytics without evidence of benefit in acute uncomplicated cough 1
• Missing serious underlying conditions that require specific treatment rather than symptomatic management 1

Special Considerations

Cough should generally be regarded as a physiological phenomenon that helps clear mucus from the bronchial tree 1. Suppression is only logical when cough is dry, frequent, and particularly bothersome at night 1. Most episodes of acute cough are self-limiting and last 1-3 weeks 1.