What is the treatment for a non-productive cough?

Treatment of Non-Productive Cough

For non-productive cough, start with simple home remedies like honey and lemon, then escalate to dextromethorphan 60 mg (not the subtherapeutic over-the-counter dose of 30 mg) if symptoms persist, reserving first-generation antihistamines specifically for nighttime cough that disrupts sleep. 1

First-Line Approach: Non-Pharmacological Management

• Begin with honey and lemon mixtures, which are as effective as pharmacological treatments for benign viral cough and should be the initial intervention. 1
• Teach voluntary cough suppression techniques, as central modulation may be sufficient to reduce cough frequency in some patients. 1
• These simple measures avoid medication side effects and are appropriate for most acute viral causes. 2

Second-Line: Pharmacological Therapy

Dextromethorphan (Preferred Antitussive)

• Use dextromethorphan at 60 mg for maximum cough reflex suppression, not the standard over-the-counter dose which is subtherapeutic. 2, 1
• This non-sedating opiate has been shown to suppress acute cough in meta-analyses and has a superior safety profile compared to codeine. 2
• Exercise caution with higher doses as some combination preparations contain paracetamol or other ingredients that could lead to toxicity. 2, 1
• Dextromethorphan is FDA-approved as a cough suppressant. 3

Menthol Inhalation (Short-Term Relief)

• Menthol by inhalation suppresses the cough reflex acutely but provides only short-lived relief. 2, 1
• Prescribe as menthol crystals BPC or proprietary capsules for quick but temporary symptom control. 2

First-Generation Antihistamines (Nocturnal Cough Only)

• Reserve sedative antihistamines specifically for nocturnal cough when sleep disruption is the primary concern. 2, 1
• These agents suppress cough but cause drowsiness, making them unsuitable for daytime use. 2
• The sedative effect is actually beneficial when cough interferes with sleep. 4

What NOT to Use

• Avoid codeine and pholcodine entirely—they have no greater efficacy than dextromethorphan but carry a much greater adverse side effect profile including drowsiness, nausea, constipation, and risk of physical dependence. 2, 1
• Newer non-sedating antihistamines are ineffective for cough reduction and should not be used. 2

Chronic Non-Productive Cough: Identify the Underlying Cause

If cough persists beyond 3 weeks, the approach shifts to identifying treatable causes rather than just suppressing symptoms:

Upper Airway Cough Syndrome (UACS, formerly Post-Nasal Drip)

• Start empiric therapy with a first-generation antihistamine/decongestant combination before extensive workup if no specific etiology is apparent. 2
• If no response to first-generation antihistamine/decongestant therapy, obtain sinus imaging as chronic sinusitis can present with completely non-productive cough. 2
• Continue treatment for minimum 3 weeks; add intranasal corticosteroids for 3 months if cough resolves. 2

Cough Variant Asthma

• Consider asthma in all chronic cough patients as it commonly presents with isolated cough. 2
• Perform methacholine challenge testing if physical examination and spirometry are non-diagnostic. 2
• Diagnosis is confirmed only after cough resolution with specific anti-asthmatic therapy. 2

Gastroesophageal Reflux Disease (GERD)

• GERD can present as "silent GERD" with cough as the only manifestation. 2
• Consider 24-hour esophageal pH monitoring if other causes are ruled out. 5

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (30 mg) when 60 mg is needed for optimal effect. 2, 1
• Prescribing codeine-based products despite their lack of efficacy advantage and increased side effects. 2, 1
• Failing to recognize that chronic cough often has multiple simultaneous causes (UACS, asthma, GERD) that each require treatment. 2, 5
• Using cough suppressants when the cough is actually productive, as this interferes with beneficial mucus clearance. 6
• Assuming normal spirometry rules out asthma—methacholine challenge is needed for cough variant asthma. 2

When to Escalate Care

Refer or investigate further if: 2

• Cough persists beyond 3 weeks despite appropriate treatment
• Patient coughs up blood
• Breathlessness is present
• Prolonged fever or systemic illness
• Patient has comorbidities (COPD, heart disease, diabetes, asthma)
• Recent hospitalization