How to manage a cough without fever or runny nose?

Management of Cough Without Fever or Runny Nose

For an isolated cough without fever or runny nose, start with simple home remedies like honey and lemon, which are as effective as pharmacological treatments for benign viral cough, and reserve medications for cases where symptoms are distressing or interfering with daily activities. 1

Initial Assessment and Red Flags

Before treating symptomatically, you must rule out serious conditions by asking directly about:

• Hemoptysis (any blood in sputum requires immediate specialist referral for bronchoscopy) 1
• Breathlessness (assess for asthma, anaphylaxis, or pneumonia) 1
• Systemic illness (weight loss, night sweats, malaise suggesting underlying disease) 1
• Foreign body aspiration (especially with sudden onset or choking history) 1
• Voice changes (may indicate vocal cord palsy) 1
• Duration beyond 3 weeks (no longer acute cough; requires full diagnostic workup) 1, 2

Physical examination findings that warrant chest radiograph: dullness on percussion, bronchial breathing, or crackles on auscultation suggesting pneumonia 1

First-Line Treatment Algorithm

Step 1: Non-Pharmacological Approaches

• Honey and lemon mixture as initial treatment—this provides central modulation of the cough reflex and is recommended by the British Thoracic Society as the simplest, cheapest, and equally effective option 1, 3
• Voluntary cough suppression techniques—simple conscious suppression may be sufficient to reduce cough frequency 1, 3
• Adequate hydration and humidified air to help thin secretions 2

Step 2: Pharmacological Options (If Non-Pharmacological Measures Insufficient)

For dry, non-productive cough:

• Dextromethorphan 60 mg is the recommended dose for maximum cough reflex suppression (standard OTC doses of 15-30 mg are subtherapeutic) 1, 2, 3

  • Can be given as a single 60 mg dose or divided as 30 mg twice daily 3
  • Maximum daily dose is 120 mg 3
  • Critical caveat: Check combination products carefully—many contain paracetamol or other ingredients that require dose adjustment at higher dextromethorphan doses 1, 2, 3
  • Dextromethorphan has superior safety profile compared to codeine-based antitussives 2, 3

• Menthol inhalation (menthol crystals or proprietary capsules) provides acute but short-lived relief for quick temporary symptom control 1, 2, 3

• First-generation sedating antihistamines (like chlorpheniramine) are suitable specifically for nocturnal cough disrupting sleep, but cause drowsiness and should not be used if patient needs to operate machinery 1, 2, 3

• Benzonatate 100-200 mg three to four times daily is an alternative peripherally-acting antitussive with different adverse effect profile, preferred when opioids are contraindicated 2, 4

For productive cough with mucus:

• Guaifenesin 200-400 mg every 4 hours (up to 6 times daily) to help loosen mucus and make coughs more productive 5, 6
• Extended-release formulations available for 12-hourly dosing 6

Medications to Avoid

• Codeine or pholcodine: No greater efficacy than dextromethorphan but significantly more adverse effects including drowsiness, nausea, constipation, and physical dependence—not recommended 1, 2, 3
• Standard OTC antihistamines alone: Not effective for cough suppression unless used for their sedative properties at night 1
• Antibiotics: Not indicated for viral cough even if producing phlegm 1, 7

Duration of Treatment and Follow-Up

• Acute viral cough typically lasts 2-3 weeks and is self-limiting 2
• Use antitussives for short-term symptomatic relief only (typically 7-14 days maximum) 2, 3
• If cough persists beyond 3 weeks: Discontinue symptomatic treatment and perform full diagnostic workup for post-viral cough, pertussis, asthma, GERD, post-nasal drip, or other chronic conditions 1, 2, 3

Special Populations and Comorbidities

Patients with diabetes:

• Use sugar-free formulations of dextromethorphan 2
• Monitor blood glucose more frequently when starting any new medication 2
• Avoid combination products with decongestants (pseudoephedrine) if hypertensive 2

Patients with chronic conditions (COPD, heart disease, asthma):

• Require medical evaluation rather than self-treatment 1

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (15-30 mg) that provide inadequate relief 2, 3
• Prescribing codeine-based products which have no efficacy advantage but increased side effects 1, 2, 3
• Continuing antitussive therapy beyond 3 weeks without reassessing for underlying causes 2, 3
• Using antitussives for productive cough where clearance of secretions is beneficial 3
• Failing to check for serious underlying conditions before treating symptomatically 1

Evidence Quality Note

The British Thoracic Society guidelines acknowledge that evidence for OTC cough preparations is limited, with small numbers of studies showing conflicting results 1, 8, 9. However, the consistent recommendation across guidelines is that simple home remedies are as effective as pharmacological treatments for benign viral cough, with dextromethorphan at appropriate doses (60 mg) being the preferred medication when pharmacological treatment is needed 1, 2, 3.