What is the role of montelukast (Singulair) in treating nighttime coughs associated with asthma or allergic rhinitis?

Montelukast for Nighttime Cough

Montelukast is not recommended as first-line therapy for isolated nighttime cough, as nocturnal cough reporting is unreliable and does not correlate with objective measurements, and there is no evidence that nighttime cough is actually worse than daytime cough in children with stable asthma. 1

Understanding Nocturnal Cough as a Symptom

• The major limitation of using nocturnal cough as an indication for treatment is the poor reliability and inconsistency of its reporting compared to objective measurements, with Cohen's kappa of only 0.3 between subjective and objective assessment 1

• Only one-third of children with isolated nocturnal cough (without wheezing, shortness of breath, or chest tightness) actually have an asthma-like illness 1

• Objective studies show cough frequency is actually higher during the day than at night in children with stable asthma receiving inhaled corticosteroids 1

• Nocturnal cough may simply be perceived as more troublesome rather than being objectively more severe 1

When Montelukast May Be Appropriate

If nighttime cough is part of confirmed asthma or allergic rhinitis, montelukast has a defined but limited role:

For Asthma-Related Cough:

• Montelukast is FDA-approved for long-term asthma management in patients 12 months and older, taken once daily in the evening 2

• It should be used as add-on therapy to inhaled corticosteroids for moderate-to-severe persistent asthma, not as monotherapy replacement 3

• Montelukast does NOT provide immediate relief of asthma symptoms and should never be used for acute asthma attacks 2

For Allergic Rhinitis-Related Cough:

• The American Academy of Allergy, Asthma, and Immunology recommends intranasal corticosteroids as the most effective first-line treatment for upper airway cough syndrome secondary to allergic rhinitis, not montelukast 4

• A single RCT in adolescents and adults with allergic rhinitis showed significant improvement in daytime cough with intranasal mometasone (p=0.049), but no difference in nighttime cough 1

• Montelukast is less effective than intranasal corticosteroids for allergic rhinitis symptoms 4, 5

• Reserve montelukast for patients who fail or cannot tolerate intranasal corticosteroids 4, 5

Clinical Algorithm for Nighttime Cough

Step 1: Determine if cough is truly nocturnal-predominant

• Recognize that parental/patient reporting of nocturnal cough is unreliable 1
• Consider that cough may be equally present during the day but less noticed 1

Step 2: Identify underlying cause

• If wheezing, shortness of breath, or chest tightness present → likely asthma 1
• If nasal symptoms predominate → consider allergic rhinitis 1
• If isolated cough without other symptoms → unlikely to be asthma 1

Step 3: Treatment hierarchy

• For asthma: Inhaled corticosteroids remain first-line; montelukast as add-on therapy 3
• For allergic rhinitis: Intranasal corticosteroids first-line; montelukast only if first-line fails 4, 5
• For isolated nocturnal cough: Do not empirically treat with montelukast without confirmed diagnosis 1

Specific Advantages When Both Conditions Present

• For patients with both asthma and allergic rhinitis, montelukast offers the advantage of treating both upper and lower airway disease simultaneously with a single once-daily oral medication 4, 5

• In patients with confirmed asthma and seasonal allergic rhinitis, montelukast reduced both rhinitis symptoms and improved asthma control, including reduced beta-agonist use 6

• Montelukast improved quality of life in patients with both asthma and comorbid allergic rhinitis 7, 3

Critical Pitfalls to Avoid

• Do not use montelukast for acute symptom relief - it has no role in treating acute cough or asthma attacks 2

• Do not assume nocturnal cough equals asthma - only one-third of children with isolated nocturnal cough have asthma-like illness 1

• Do not bypass intranasal corticosteroids - they are superior to montelukast for allergic rhinitis and should be tried first 4, 5

• Be aware of neuropsychiatric events - though evidence of causation is conflicting, neuropsychiatric events have been reported with leukotriene antagonists 4

• For non-allergic causes of cough, montelukast is not indicated 4

Dosing When Appropriate

• Adults and children ≥15 years: 10 mg once daily in the evening 2
• Children 6-14 years: 5 mg chewable tablet once daily in the evening 2
• Children 2-5 years: 4 mg chewable tablet or oral granules once daily in the evening 2
• Take consistently every day, not as needed 2