What is the best treatment for the common cold?

Treatment of the Common Cold

For adults and older children with the common cold, combination antihistamine-decongestant-analgesic products provide the most effective symptom relief, with approximately 1 in 4 patients experiencing significant improvement—this represents superior efficacy compared to single-agent therapy. 1, 2

Core Treatment Strategy

The common cold is a self-limiting viral illness requiring only symptomatic management. 1 Antibiotics are never indicated and contribute to antimicrobial resistance without providing any clinical benefit. 3, 1, 2

First-Line Therapy: Combination Products

• Use combination antihistamine-decongestant-analgesic products as primary therapy for patients with multiple symptoms (nasal congestion, rhinorrhea, headache, malaise). 1, 2
• These combinations show an odds ratio of treatment failure of 0.47 (95% CI 0.33-0.67; number needed to treat = 5.6) compared to placebo. 1
• Effective formulation: First-generation antihistamine (brompheniramine) + sustained-release pseudoephedrine reduces congestion and rhinorrhea. 1
• Critical limitation: No evidence of effectiveness in young children. 3

Targeted Single-Agent Therapy

When patients present with isolated symptoms, use specific agents:

• For nasal congestion: Oral pseudoephedrine 4 or topical nasal decongestants (oxymetazoline) provide modest benefit. 1, 2 Limit topical decongestants to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa). 1, 2

• For rhinorrhea: Ipratropium bromide nasal spray effectively reduces runny nose but does not improve nasal congestion. 3, 1, 2

• For headache, ear pain, muscle/joint pain, and malaise: NSAIDs (ibuprofen 400-800 mg every 6-8 hours) provide significant benefits and also improve sneezing. 3, 1, 2

• For nasal obstruction and rhinorrhea: Acetaminophen/paracetamol 5 may help these specific symptoms but does not improve sore throat, malaise, sneezing, or cough. 3, 2

• For cough: Dextromethorphan 6 at 60 mg provides maximum effect, though standard over-the-counter doses are likely subtherapeutic. 1 Honey and lemon is recommended as a simple, inexpensive alternative with patient-reported benefit. 1

Evidence-Based Adjunctive Therapies

Zinc Lozenges (Time-Critical)

• Zinc acetate or zinc gluconate lozenges at ≥75 mg/day significantly reduce cold duration BUT only if started within 24 hours of symptom onset. 3, 1, 2
• No benefit if symptoms are already established beyond 24 hours. 1, 2
• Continue throughout the cold at this dose. 3
• Potential side effects include bad taste and nausea. 1, 2

Nasal Saline Irrigation

• Provides modest symptom relief, particularly beneficial in children. 3, 1, 2
• Helps dilute secretions and facilitate elimination. 1

Vitamin C

• May be worthwhile for patients to test on an individual basis given consistent effects on duration and severity, low cost, and safety. 3, 2

Pediatric-Specific Management

• Acetaminophen/paracetamol for fever and pain. 1
• Over-the-counter cold medications should not be used in children younger than four years. 1
• Nasal saline irrigation is particularly beneficial in this age group. 3, 1

Treatments That Do NOT Work (Avoid These)

• Antibiotics: No benefit for uncomplicated common cold, cause adverse events, and drive antimicrobial resistance. 3, 1, 2
• Intranasal corticosteroids: Ineffective for acute cold symptoms. 1, 2
• Non-sedating antihistamines (loratadine, cetirizine, fexofenadine): Ineffective for common cold. 2, 7
• Steam/heated humidified air: No proven benefits or harms. 3, 2
• Echinacea: Most products are not effective; any potential effects are of questionable clinical relevance. 3, 2

When Symptoms Persist Beyond 10 Days

• Approximately 25% of patients continue with cough and nasal discharge up to 14 days—this is normal and does not indicate bacterial infection. 1, 2
• Symptoms persisting >10 days without improvement classify as post-viral rhinosinusitis. 1, 7
• Consider intranasal corticosteroids for post-viral symptoms. 1
• Only suspect bacterial infection if at least 3 of 5 criteria are present: discolored (purulent) nasal discharge, severe local pain, fever >38°C (100.4°F), "double sickening" pattern (initial improvement followed by worsening), elevated inflammatory markers. 1
• Key point: Only 0.5-2% of viral upper respiratory infections develop bacterial complications. 1, 7

Red Flags Requiring Further Evaluation

• Hemoptysis (any amount warrants chest radiograph). 1
• Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement. 1
• Severe unilateral facial pain suggesting bacterial sinusitis. 1
• "Double sickening" pattern. 1
• Acute breathlessness. 1

Common Pitfalls to Avoid

• Do not diagnose bacterial sinusitis in the first 10 days of symptoms—87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics. 1
• Inappropriate antibiotic prescribing based on symptom duration alone or patient/family pressure. 1, 7
• Prolonged decongestant use leading to rebound congestion—strictly limit to short-term use. 1, 2, 7
• Missing the 24-hour window for zinc supplementation effectiveness. 1, 2, 7
• Unrealistic patient expectations—cold symptoms typically last 7-10 days, with up to 25% lasting 14 days. 1, 2