What is the best treatment for an itchy throat at night with cough?

Treatment for Itchy Throat at Night with Cough

For an itchy throat at night with cough, start with honey and lemon as a simple home remedy, then add dextromethorphan 30-60 mg at bedtime for cough suppression, and consider adding a first-generation sedating antihistamine specifically for nighttime symptom relief. 1, 2

Initial Approach: Non-Pharmacological First

• Simple home remedies like honey and lemon are as effective as pharmacological treatments for benign viral cough and should be tried first. 1, 2
• Voluntary cough suppression techniques through central modulation may be sufficient to reduce cough frequency in some patients. 1

Pharmacological Treatment Algorithm

First-Line: Dextromethorphan

• Dextromethorphan is the recommended first-line antitussive agent due to its superior safety profile compared to opioid alternatives. 1, 2
• The optimal dose is 60 mg for maximum cough reflex suppression, as standard over-the-counter dosing (15-30 mg) is often subtherapeutic. 1, 2
• Dextromethorphan is FDA-approved to temporarily relieve cough and help patients get to sleep. 3
• The antitussive effect can be prolonged at the 60 mg dose. 1
• Caution: Some combined preparations contain other ingredients like acetaminophen, so check labels when using higher doses. 1

For Nighttime Symptoms: Add Sedating Antihistamine

• First-generation sedative antihistamines (like promethazine or chlorpheniramine) can suppress cough and are particularly suitable for nocturnal cough due to their sedative properties. 1, 2, 4
• The sedation caused by these antihistamines is valuable when cough is disturbing sleep. 4
• This combination approach (dextromethorphan plus sedating antihistamine) is recommended by the American College of Physicians for nocturnal cough. 2

Alternative Quick Relief Option

• Menthol by inhalation provides acute but short-lived cough suppression and can be used as an adjunct for immediate relief. 1, 2
• Can be prescribed as menthol crystals or proprietary capsules. 1

What NOT to Use

• Codeine is not recommended as it has no greater efficacy than dextromethorphan but has a much worse adverse effect profile (drowsiness, nausea, constipation, physical dependence). 1, 2

When to Consider Other Diagnoses

If Symptoms Persist Beyond 3 Weeks:

• Cough lasting more than 3 weeks requires a full diagnostic workup rather than continued antitussive therapy to evaluate for alternative diagnoses. 1
• Consider postinfectious cough, upper airway disease (post-nasal drip), gastroesophageal reflux disease, or asthma as potential causes. 5

For Postinfectious Cough (if applicable):

• Try inhaled ipratropium bromide first before central antitussives, as it may attenuate postinfectious cough. 5, 1
• If ipratropium fails and symptoms are severe, consider dextromethorphan. 1
• For severe paroxysms of postinfectious cough, consider prednisone 30-40 mg daily for a short, finite period. 5, 1, 2

For Upper Airway Disease/Post-Nasal Drip:

• If prominent upper airway symptoms are present (nasal stuffiness, sensation of secretions draining), consider a 1-month trial of topical nasal corticosteroid. 5
• Intranasal steroids given for 2 weeks have been shown effective for cough due to allergic rhinitis. 5

For Gastroesophageal Reflux:

• If clinical history suggests reflux (symptoms worse when lying down, heartburn), consider proton pump inhibitors (omeprazole 20-40 mg twice daily before meals) for at least 8 weeks. 5

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (15-30 mg) that may not provide adequate relief - aim for 30-60 mg for effective cough suppression. 1, 2
• Prescribing codeine-based antitussives which have no efficacy advantage but increased side effects. 1, 2
• Continuing antitussive therapy beyond short-term use (typically less than 7 days) without investigating underlying causes. 2
• Using antitussives for productive cough where clearance of secretions is beneficial. 2