Management of the Common Cold
Primary Recommendation
The common cold is a self-limiting viral illness requiring only symptomatic management—combination antihistamine-decongestant-analgesic products provide the most effective relief (1 in 4 patients experience significant improvement), and antibiotics are never indicated. 1, 2
Symptomatic Treatment Algorithm
First-Line Therapy: Combination Products
- Use combination antihistamine-decongestant-analgesic products as your primary treatment strategy, with an odds ratio of treatment failure of 0.47 (95% CI 0.33-0.67; number needed to treat = 5.6). 1
- Specifically, first-generation antihistamine (brompheniramine) combined with sustained-release pseudoephedrine effectively reduces congestion and rhinorrhea. 1
- These combination products work better than single agents and address multiple symptoms simultaneously. 2
Targeted Single-Agent Therapy
For nasal congestion:
- Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit. 1
- Topical nasal decongestants are effective but limit use to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa). 1, 2
For rhinorrhea (runny nose):
- Ipratropium bromide nasal spray effectively reduces rhinorrhea but does not improve nasal congestion. 1, 2
For pain, fever, and systemic symptoms:
- 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. 1, 2
For cough:
- Dextromethorphan (60 mg for maximum effect) suppresses acute cough, though standard over-the-counter doses are likely subtherapeutic. 1, 3
- Menthol inhalation provides acute but short-lived cough suppression. 1
- Avoid codeine and other opiate antitussives—they have limited efficacy for upper respiratory infection cough and significant adverse effects. 4, 1
- Honey and lemon is recommended as a simple, inexpensive home remedy with patient-reported benefit. 1
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
- Use zinc acetate or zinc gluconate formulations. 1
- Critical timing caveat: No benefit if symptoms already established beyond 24 hours. 1, 2
- Potential side effects include bad taste and nausea. 1, 2
Nasal Saline Irrigation
- Provides modest symptom relief, particularly beneficial in children. 1, 2
- Helps dilute secretions and facilitate elimination. 1
What Does NOT Work (Avoid These)
Antibiotics:
- Antibiotics have no benefit for uncomplicated common cold and contribute to antimicrobial resistance. 4, 1, 2
- They do not affect symptom duration nor prevent complications, even when risk factors are present. 4
Other ineffective treatments:
- Intranasal corticosteroids for acute cold symptoms. 1, 2
- Non-sedating antihistamines (newer generation) are ineffective. 1
- Zinc preparations are not recommended for established colds beyond 24 hours. 4
- Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) lack proven efficacy. 4
Pediatric-Specific Management
- Acetaminophen/paracetamol for fever and pain. 1
- Over-the-counter cough and cold medications should not be used in children younger than four years due to potential harm without benefit. 4
- Nasal saline irrigation is particularly beneficial in children. 1
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. 1, 5
- Symptoms persisting >10 days without improvement classify as post-viral rhinosinusitis. 1, 5
- Consider intranasal corticosteroids for post-viral symptoms. 1, 5
- Continue symptomatic treatment with combination products. 5
Red Flags Requiring Further Evaluation
Suspect bacterial complication if:
- Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement. 1, 5
- Severe unilateral facial pain suggesting bacterial sinusitis. 1, 5
- "Double sickening" pattern (initial improvement followed by worsening). 1, 5
- At least 3 of 5 criteria present: discolored (purulent) nasal discharge, severe local pain, fever >38°C, "double sickening" pattern, elevated inflammatory markers. 1, 5
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. 1
Key point: Only 0.5-2% of viral upper respiratory infections develop bacterial complications. 1, 5
Patient Education
- Cold symptoms typically last 7-10 days. 4, 1
- Up to 25% may have symptoms for 14 days. 1, 5
- The illness is self-limiting and viral—antibiotics will not help. 4, 1
- Hand hygiene is the best way to prevent transmission of cold viruses. 6
Special Populations
- Acetaminophen/paracetamol is first-line for pain and fever in pregnant women. 1