What is the treatment for nasal congestion, headache, and runny nose with a cough producing non-purulent sputum?

Treatment for Acute Viral Upper Respiratory Infection with Cough

For this acute viral upper respiratory infection (common cold) with non-purulent cough lasting 10 days, symptomatic treatment with a first-generation antihistamine/decongestant combination is the most effective approach, while antibiotics should be avoided entirely. 1

Antibiotics Are Not Indicated

• Antibiotics provide no benefit for the common cold or acute purulent rhinitis and cause significant adverse effects—routine use is not recommended. 1
• This presentation (nasal congestion, headache, runny nose with non-purulent sputum for 10 days) is consistent with acute viral rhinosinusitis, not bacterial infection. 1

First-Line Symptomatic Treatment

Antihistamine-Decongestant Combinations (Most Effective)

• Antihistamine-analgesic-decongestant combinations provide general benefit in adults with the common cold and are the most effective first-line treatment. 1, 2
• Specific effective combinations include:
  • Dexbrompheniramine 6 mg + pseudoephedrine 120 mg (sustained-release), twice daily 2, 3
  • Azatadine 1 mg + pseudoephedrine 120 mg (sustained-release), twice daily 2, 3
  • Brompheniramine + pseudoephedrine (sustained-release) 3
• First-generation antihistamines work primarily through anticholinergic properties to reduce secretions and cough, not through antihistamine effects. 2, 3
• Start with once-daily dosing at bedtime for a few days before increasing to twice-daily to minimize sedation. 2, 3
• Most patients improve within days to 2 weeks of initiating therapy. 2

Decongestants Alone

• Multiple doses of oral decongestants (pseudoephedrine) have a small positive effect on nasal congestion in adults without increasing short-term adverse events. 1, 4
• Topical nasal decongestants (oxymetazoline, xylometazoline) can be used for rapid relief but must be limited to 3-5 consecutive days maximum to avoid rhinitis medicamentosa (rebound congestion). 2, 5, 6

Analgesics for Symptom Relief

• NSAIDs (ibuprofen, naproxen) significantly improve headache, ear pain, muscle/joint pain, and sneezing, though they do not reduce total symptom score or duration. 1
• Paracetamol (acetaminophen) may help relieve nasal obstruction and rhinorrhea but does not improve other cold symptoms including cough. 1

Cough Suppression

• Dextromethorphan or codeine can provide short-term symptomatic relief of coughing. 1, 7
• Central cough suppressants are recommended for short-term use in chronic bronchitis but are also reasonable for bothersome acute viral cough. 1

Treatments That Do NOT Work

• Nasal corticosteroids do not provide symptomatic relief for the common cold. 1
• Antihistamines alone have only limited short-term benefit (days 1-2) on overall symptoms in adults, with no clinically significant effect on nasal obstruction, rhinorrhea, or sneezing. 1
• Newer-generation antihistamines (loratadine, fexofenadine, cetirizine) with or without pseudoephedrine are ineffective for acute cough in postviral upper respiratory infection. 2, 3
• Steam/heated humidified air shows no benefits. 1
• Vitamin C supplementation does not help once symptoms have started. 1

Adjunctive Therapies to Consider

• Ipratropium bromide nasal spray effectively reduces rhinorrhea and nose-blowing frequency, though it does not help nasal congestion. 1
• Nasal saline irrigation may provide benefits for relieving acute URTI symptoms, mainly in children, and is considered a reasonable option. 1
• Probiotics may be more beneficial than placebo for preventing acute URTIs, though evidence quality is very low. 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics—they cause harm without benefit in viral URIs. 1
• Do not use topical nasal decongestants beyond 5 days—this causes rhinitis medicamentosa. 2, 5, 6
• Do not prescribe newer-generation antihistamines for cough—they lack the anticholinergic properties needed for efficacy. 2, 3
• Monitor blood pressure if using decongestants, as they can worsen hypertension and cause tachycardia. 2
• Be cautious with first-generation antihistamines in patients with glaucoma, urinary retention, or benign prostatic hypertrophy. 2, 3

When to Reassess

• If symptoms persist beyond 2 weeks despite adequate treatment, consider evaluation for bacterial sinusitis, upper airway cough syndrome, or other complications. 2
• Bacterial sinusitis is suggested by worsening symptoms after initial improvement, high fever (>39°C), purulent nasal discharge, and facial pain lasting >10 days. 1