What is the best treatment for a hyperactive airway cough at night?

Treatment of Hyperactive Airway Cough at Night

For nocturnal cough due to hyperactive airways, inhaled corticosteroids should be the first-line treatment, with consideration of adding a leukotriene receptor antagonist if response is incomplete. 1

Initial Assessment and Diagnosis

Before initiating treatment, determine if the nocturnal cough represents asthma or cough-variant asthma (CVA):

• Bronchial challenge testing (methacholine) can demonstrate airway hyperresponsiveness, which distinguishes asthma from other causes 1
• Non-invasive inflammatory markers such as fractional exhaled nitric oxide (FeNO) or sputum eosinophil counts predict corticosteroid responsiveness 1
• The presence of eosinophilic airway inflammation is associated with more favorable response to corticosteroids 1

Important caveat: Nocturnal cough alone is an unreliable indicator of asthma severity—only one-third of children with isolated nocturnal cough actually have asthma-like illness 1. However, if hyperactive airways are confirmed, treatment should proceed.

First-Line Treatment: Inhaled Corticosteroids

Start with inhaled corticosteroids at standard doses for 4-8 weeks and monitor response 1:

• Dosing: Begin with low to medium doses equivalent to beclomethasone 200-800 mcg daily 1
• Administration: Twice-daily dosing is superior to once-daily dosing for fluticasone, providing greater therapeutic benefit 2
• Delivery: Use proper inhaler technique with large volume spacers for metered-dose inhalers 1
• Duration: Allow 4-8 weeks for full assessment of response 1

The evidence supporting ICS as first-line therapy is strong for cough-variant asthma specifically 1, though evidence for non-specific chronic cough without confirmed asthma is weaker 3.

Stepwise Escalation if Response is Incomplete

If nocturnal cough persists after initial ICS therapy:

1. Increase ICS dose up to daily equivalent of 2000 mcg beclomethasone 1
2. Add leukotriene receptor antagonist (montelukast 10 mg daily) - there is specific evidence supporting this combination in cough-variant asthma 1, 4, 5
3. Consider beta-agonists in combination with ICS, though evidence is less robust for isolated cough 1

Do not use long-acting beta-agonists at step 3 in cough-variant asthma, as there is no evidence supporting their use at this stage 4.

Symptomatic Relief for Nocturnal Cough

While addressing the underlying hyperactive airway with ICS, symptomatic relief can be provided:

• First-generation sedating antihistamines are particularly suitable for nocturnal cough due to their sedative properties 6
• Dextromethorphan at 30-60 mg can provide cough suppression (standard OTC doses are often subtherapeutic) 6
• Honey and lemon may be as effective as pharmacological treatments for benign cough 6

Avoid codeine - it has no greater efficacy than dextromethorphan but significantly more adverse effects including drowsiness, nausea, constipation, and physical dependence 6, 7.

Special Considerations and Common Pitfalls

High-dose ICS for severe nocturnal cough: One study showed fluticasone 2 mg daily for 3 days followed by 1 mg daily for 11 days reduced nocturnal cough frequency significantly, though placebo also showed improvement 8, 9. The clinical impact of very high-dose ICS is likely modest 9.

Reassess if no response: If cough persists beyond 3 weeks despite appropriate ICS therapy, reconsider alternative diagnoses 6:

• Upper airway cough syndrome (post-nasal drip)
• Gastroesophageal reflux disease (commonly coexists with asthma) 1, 4
• Non-asthmatic eosinophilic bronchitis (responds to ICS but lacks airway hyperresponsiveness) 1

Medication side effects: ACE inhibitors can cause chronic cough in 2-17% of children, resolving within 3-7 days of discontinuation 1.

Treatment Algorithm Summary

1. Confirm hyperactive airways with bronchial challenge testing or inflammatory markers 1
2. Start ICS at standard doses (beclomethasone equivalent 200-800 mcg daily) twice daily 1, 2
3. Add symptomatic relief with sedating antihistamines for nighttime use 6
4. If incomplete response after 4-8 weeks: Increase ICS dose and add montelukast 10 mg daily 1, 4
5. If still inadequate: Consider short-course oral corticosteroids (prednisone 30-40 mg daily) 6
6. If no response: Reassess diagnosis and consider alternative causes 1, 6