What are the best management options for a patient with head congestion, considering their past medical history, such as hypertension, asthma, or chronic obstructive pulmonary disease (COPD), and allergies?

Management of Head Congestion

Intranasal corticosteroids are the most effective first-line treatment for head congestion, particularly when symptoms are moderate to severe or persistent, as they address the underlying mucosal inflammation and control all major nasal symptoms including congestion. 1

Initial Treatment Algorithm

For Mild, Intermittent Congestion

• Second-generation oral antihistamines (loratadine, desloratadine, fexofenadine, cetirizine) can be used for allergic rhinitis but have limited objective effect on nasal congestion alone 1
• These agents are most effective for rhinorrhea, sneezing, and itching rather than congestion 1
• Intranasal antihistamines (azelastine 0.1% or olopatadine 0.6%) provide superior congestion relief compared to oral antihistamines, with onset of action at 15-30 minutes 1
• Azelastine causes bitter taste in 19.7% and somnolence in 11.5% of patients 1

For Moderate to Severe Congestion

• Intranasal corticosteroids should be considered as initial therapy without requiring a trial of antihistamines first 1
• These are the most potent long-term pharmacologic treatment for congestion, controlling sneezing, itching, rhinorrhea, and nasal congestion 1, 2
• Direct spray away from the nasal septum to minimize local side effects (nasal irritation, bleeding) 1
• Use the lowest effective dose, particularly in children 1
• Examine the nasal septum periodically to ensure no mucosal erosions are developing 1

Decongestant Therapy

Oral Decongestants

• Pseudoephedrine (60 mg every 4-6 hours) or phenylephrine reduce nasal congestion in both allergic and nonallergic rhinitis 1, 3
• Pseudoephedrine is more effective than phenylephrine due to first-pass metabolism issues with phenylephrine 4
• Combination with antihistamines may be beneficial, though less effective than intranasal corticosteroids alone 1

Topical Decongestants

• Use only for short-term relief (maximum 3 days) for acute bacterial/viral infections or exacerbations 1
• Risk of rhinitis medicamentosa (rebound congestion) develops in some patients after 3 days, though others tolerate up to 4-6 weeks 1
• Given this variability, instruct all patients about rebound risk with use beyond 3 days 1
• Provide faster and more intense relief than oral agents but shorter duration 4

Special Considerations for Comorbidities

Hypertension

• Oral decongestants are generally well tolerated in patients with controlled hypertension 1
• Pseudoephedrine causes minimal blood pressure elevation (systolic increase 0.99 mmHg, no diastolic effect) in most patients 1
• Monitor blood pressure due to interindividual variation in response 1
• Elevation is very rarely noted in normotensive patients and only occasionally in those with controlled hypertension 1

Asthma and COPD

• Intranasal corticosteroids are safe and preferred as they have minimal systemic absorption at recommended doses 1
• Oral decongestants should be used with caution but are not contraindicated 1
• β-agonists in decongestant combinations may rarely precipitate angina in elderly patients; first treatment should be supervised 1
• Avoid ipratropium-containing products in patients with glaucoma; use mouthpiece if necessary 1

Drug Interactions and Contraindications

• Use oral and topical decongestants with caution in patients with cardiac arrhythmia, angina pectoris, cerebrovascular disease, bladder neck obstruction, glaucoma, or hyperthyroidism 1
• Avoid in young children due to risk of agitated psychosis, ataxia, hallucinations, and death 1

Adjunctive Therapies

Leukotriene Receptor Antagonists

• Montelukast has similar efficacy to oral antihistamines for allergic rhinitis 1
• Combination with antihistamines may have additive effect, but this approach is less efficacious than intranasal corticosteroids 1

Nasal Saline

• Topical saline is beneficial as sole or adjunctive treatment for chronic rhinorrhea and rhinosinusitis 1

Allergen Immunotherapy

• Consider for patients with allergic rhinitis who have demonstrable specific IgE antibodies to clinically relevant allergens when symptoms are inadequately controlled by avoidance and medication 1

Common Pitfalls to Avoid

• Never prescribe systemic corticosteroids before trying intranasal corticosteroids for rhinitis management 1
• Do not use first-generation antihistamines as first-line therapy due to sedation, performance impairment, and anticholinergic effects 1
• Avoid prolonged topical decongestant use beyond 3 days without explicit patient education about rebound congestion risk 1
• Do not assume oral decongestants are contraindicated in controlled hypertension; they are generally safe with monitoring 1
• Recognize that phenylephrine may be ineffective due to poor bioavailability; pseudoephedrine is preferred 4