How do I relieve nasal congestion?

How to Relieve Nasal Congestion

Start with intranasal corticosteroids (fluticasone, mometasone) as first-line therapy for most cases of nasal congestion, as they are the most effective monotherapy with minimal side effects and no risk of rebound congestion. 1

First-Line Treatment Approach

Intranasal corticosteroids are the gold standard for nasal congestion management:

• Fluticasone propionate nasal spray provides symptom relief starting within 12 hours, with maximum benefit achieved after several days of regular use 1, 2
• Dosing for adults: 2 sprays per nostril once daily (200 mcg total) or 1 spray per nostril twice daily 2
• These medications work through anti-inflammatory mechanisms rather than vasoconstriction, preventing rebound congestion that occurs with topical decongestants 3
• They are effective for all types of rhinitis including allergic, nonallergic, and congestion from upper respiratory infections 4, 1

Rapid Relief Options (Short-Term Use Only)

For immediate symptom relief, topical decongestants provide the fastest action:

• Oxymetazoline (Afrin) nasal spray works within minutes through nasal vasoconstriction 1, 5
• Critical limitation: Use for maximum 3-5 days only to prevent rhinitis medicamentosa (rebound congestion) 1, 3, 5
• Rebound congestion can develop as early as the third or fourth day of continuous use 4, 3
• If you need rapid relief while starting intranasal corticosteroids, apply oxymetazoline first, wait 5 minutes, then apply the corticosteroid for better penetration 3, 5

Oral Decongestant Alternative

Pseudoephedrine is an effective oral option when topical therapy is contraindicated:

• Provides temporary relief of nasal congestion through systemic vasoconstriction 4, 6
• Associated with small increases in systolic blood pressure (0.99 mmHg) and heart rate (2.83 beats/min) 4
• Use with caution in patients with hypertension, arrhythmias, coronary artery disease, hyperthyroidism, closed-angle glaucoma, or bladder neck obstruction 4
• Side effects include insomnia, irritability, palpitations, and loss of appetite 4
• Avoid in children under 6 years due to risk of serious adverse events including agitated psychosis, ataxia, hallucinations, and death 4

Important note: Phenylephrine, commonly substituted for pseudoephedrine in over-the-counter products, has not been well-established as effective due to extensive gut metabolism 4

Treatment Algorithm by Clinical Scenario

For acute congestion (common cold, acute sinusitis):

• First choice: Topical oxymetazoline for ≤3-5 days 5
• Alternative: Oral pseudoephedrine if topical contraindicated 5
• Adjunct: Nasal saline irrigation for symptomatic relief 1, 5

For allergic rhinitis with congestion:

• Start: Intranasal corticosteroid as first-line 1, 5
• If inadequate response: Add intranasal antihistamine (azelastine or olopatadine) 1, 5
• For severe obstruction: Short-term topical oxymetazoline (≤3-5 days) while starting intranasal corticosteroid 5

For chronic or recurrent congestion:

• Intranasal corticosteroids should be the primary treatment rather than repeated courses of topical decongestants 5
• Continue for several weeks as maximum benefit takes time to develop 2

Adjunctive Therapy

Nasal saline irrigation provides symptomatic relief with minimal risk of adverse effects and is particularly useful as an adjunct to other treatments 1

Critical Pitfalls to Avoid

• Never use topical decongestants beyond 3-5 days - this is the most common mistake leading to rhinitis medicamentosa 1, 3, 5
• Do not recommend antihistamines alone for nasal congestion in non-allergic patients as they are ineffective and may worsen symptoms 5
• Avoid topical decongestants in children under 4 years and use with extreme caution in children under 1 year due to narrow therapeutic window 5
• Exercise caution with decongestants during first trimester of pregnancy due to reported fetal heart rate changes 1, 5
• Do not combine caffeine with oral decongestants as adverse effects are additive 4

If Rebound Congestion Develops

If you've been using topical decongestants for more than 3-5 days and congestion worsens:

• Stop the topical decongestant immediately 3, 5
• Start intranasal corticosteroid (fluticasone or mometasone) to control symptoms while rebound effects resolve 3, 5
• For severe cases: Consider a short 5-7 day course of oral corticosteroids to hasten recovery 3, 5
• Continue intranasal corticosteroid for several weeks as nasal mucosa recovers 3