What is the recommended treatment for a frequent cough?

Treatment of Frequent Cough

Start with honey and lemon as first-line treatment, and if pharmacological therapy is needed, use dextromethorphan 30-60 mg (not the standard OTC dose of 10-15 mg which is subtherapeutic). 1, 2

Initial Non-Pharmacological Approach

• Simple home remedies like honey and lemon are as effective as medications for most acute viral coughs and should be tried first. 1, 2, 3
• These remedies work through central modulation of the cough reflex and provide a demulcent coating effect on irritated airways. 1, 2
• Voluntary cough suppression techniques may reduce cough frequency without medication in some patients. 1, 2

Pharmacological Treatment When Needed

First-Line: Dextromethorphan

• The optimal dose is 30-60 mg for maximum cough suppression, which is higher than standard over-the-counter dosing. 1, 2, 3
• Standard OTC doses of 10-15 mg are often subtherapeutic and may not provide adequate relief. 1, 3
• Maximum daily dose should not exceed 120 mg. 1, 2
• Exercise caution with combination preparations containing acetaminophen or other ingredients when using higher doses. 1, 2
• Dextromethorphan is FDA-approved as a cough suppressant. 4

Alternative Options for Specific Situations

• For nocturnal cough disrupting sleep: First-generation antihistamines (like diphenhydramine or chlorpheniramine) can suppress cough due to their sedative properties. 1, 3
• For quick but temporary relief: Menthol inhalation suppresses the cough reflex acutely but provides only short-lived benefit. 1, 2, 3

What NOT to Use

• Avoid codeine and pholcodine - they have no greater efficacy than dextromethorphan but significantly more adverse effects including drowsiness, nausea, constipation, and physical dependence. 5, 1, 3
• Over-the-counter combination cold medications are not recommended until proven effective. 3

Red Flags Requiring Medical Evaluation

Stop self-treatment and seek medical attention if: 5, 1, 3

• Cough persists beyond 3 weeks (requires full diagnostic workup, not continued antitussives)
• Coughing up blood
• Increasing breathlessness (assess for asthma or anaphylaxis)
• Fever with malaise and purulent sputum (may indicate serious lung infection)
• Pre-existing conditions like COPD, heart disease, diabetes, or asthma
• Recent hospitalization

Treatment Algorithm for Postinfectious Cough (Persisting After Acute Infection)

• First-line: Inhaled ipratropium for cough persisting after acute respiratory infection but less than 8 weeks. 1, 2
• Second-line: Inhaled corticosteroids if cough adversely affects quality of life and persists despite ipratropium. 1
• For severe paroxysms: Prednisone 30-40 mg daily for a short, finite period after ruling out other common causes. 1, 2
• Central acting antitussives like dextromethorphan should only be considered when other measures fail. 1, 2
• Antibiotics have no role unless bacterial sinusitis or early Bordetella pertussis is suspected. 1

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (10-15 mg) that provide inadequate relief. 1, 3
• Prescribing codeine-based antitussives which have no efficacy advantage but increased side effects. 1, 3
• Continuing antitussive therapy beyond 3 weeks without investigating underlying causes. 1, 3
• Not recognizing that gastroesophageal reflux disease (GORD) can cause persistent cough without gastrointestinal symptoms and may require intensive acid suppression with proton pump inhibitors for at least 3 months. 1

For Chronic Cough (Beyond 8 Weeks)

• Consider underlying causes: GORD, upper airway cough syndrome, or cough-variant asthma. 1
• Perform bronchial provocation testing in patients with normal spirometry. 1
• For unexplained chronic cough after workup, multimodality speech pathology therapy is the initial non-pharmacological approach. 1
• Gabapentin may be considered, starting at 300 mg once daily and escalating to maximum 1,800 mg daily in divided doses, with reassessment at 6 months. 1