What treatment is recommended for persistent cold symptoms, including a non-productive cough and facial pain, lasting over a month?

Chronic Rhinosinusitis with Empiric Treatment for Upper Airway Cough Syndrome

You should begin empiric treatment with a first-generation antihistamine-decongestant combination (such as brompheniramine plus sustained-release pseudoephedrine) immediately, as your symptoms lasting one month with non-productive cough and facial pain most likely represent Upper Airway Cough Syndrome (UACS) secondary to chronic rhinosinusitis, which requires 2-4 weeks of treatment before expecting significant improvement. 1, 2

Why This Approach

Your symptom constellation—persistent cough for one month with facial pain—strongly suggests UACS (previously called postnasal drip syndrome), which is the most common cause of chronic cough. 1 The facial pain component raises concern for bacterial sinusitis, but critically, you should not diagnose bacterial sinusitis during the first 10 days of symptoms because 87% of patients show sinus abnormalities on imaging during viral colds that resolve without antibiotics. 2, 3 Since you're now at one month, we've moved beyond simple viral illness.

Immediate Treatment Protocol

First-Line Therapy (Start Now)

• Combination antihistamine-decongestant-analgesic product provides the most effective relief, with 1 in 4 patients experiencing significant improvement (NNT 5.6). 2
• Specific regimen: First-generation antihistamine (brompheniramine) plus sustained-release pseudoephedrine. 1, 2
• Expected timeline: Some improvement within days to 1-2 weeks; marked improvement may take several weeks or occasionally a few months. 1
• NSAIDs (ibuprofen 400-800 mg every 6-8 hours) for facial pain, as they effectively treat headache, ear pain, and malaise. 2

Critical Timing Consideration

• Zinc is NOT helpful at this point—it only works if started within 24 hours of symptom onset, which has long passed. 2, 4

When to Escalate Treatment

If Partial Response to Antihistamine-Decongestant After 2 Weeks

• Add intranasal corticosteroid (such as fluticasone or mometasone) for persistent nasal symptoms. 1, 4
• Consider adding nasal anticholinergic agent or nasal antihistamine. 1

If No Improvement After 2-4 Weeks

Obtain sinus imaging (CT scan preferred over plain films) to evaluate for chronic sinusitis. 1 This is essential because chronic sinusitis can present with a relatively or completely non-productive cough and may lack typical acute sinusitis findings. 1

If Imaging Shows Sinusitis

• Air-fluid levels: Start antibiotics (amoxicillin-clavulanate preferred per IDSA guidelines) plus short-term nasal topical vasoconstrictor. 1
• Mucosal thickening alone: In the setting of chronic cough unresponsive to UACS treatment, treat presumptively for sinusitis. 1
• Antibiotic duration: 3-4 weeks, not the typical 10-14 days. 5

Concurrent Evaluation for Asthma

If cough persists despite treating UACS, asthma must be formally evaluated because chronic cough is frequently multifactorial. 1 Key points:

• Asthma can present as isolated cough (cough-variant asthma) without wheezing or dyspnea. 1
• Obtain spirometry and consider methacholine challenge testing if spirometry is normal but asthma is suspected. 1
• Medical history alone is unreliable for ruling in or out asthma. 1

Red Flags Requiring Immediate Evaluation

• Hemoptysis (any amount)—requires chest X-ray and possible bronchoscopy. 2
• Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement ("double sickening"). 1, 2, 4
• Severe unilateral facial pain suggesting acute bacterial sinusitis. 2, 4
• Acute breathlessness—assess for asthma exacerbation. 2

What NOT to Do

• Do NOT start antibiotics empirically without evidence of bacterial infection (at least 3 of 5 criteria: purulent discharge, severe local pain, fever >38°C, double sickening, elevated inflammatory markers). 1, 2, 4
• Do NOT use newer non-sedating antihistamines—they are ineffective for cough. 1, 2
• Do NOT use intranasal corticosteroids alone as first-line—they are ineffective for acute cold symptoms and should be added only after antihistamine-decongestant trial. 2

Common Pitfall

The most critical error is assuming all persistent cough with facial pain requires antibiotics. Only 0.5-2% of viral upper respiratory infections develop bacterial complications. 2, 4 Your symptoms likely represent post-viral inflammation with UACS, which responds to antihistamine-decongestant therapy, not antibiotics. 1, 2

If Everything Fails

• Refer to ENT specialist if no response to medical therapy for documented sinusitis. 1
• Consider allergy testing and evaluation of home/workplace environmental triggers. 1
• Check serum immunoglobulin levels to exclude acquired hypogammaglobulinemia if recurrent sinusitis develops. 1, 5