Antihistamines for Viral Upper Respiratory Infection with Rhinorrhea
Antihistamines are not recommended for viral upper respiratory infections in patients without allergic rhinitis, as they provide no significant benefit for overall symptom improvement and may worsen congestion by drying nasal mucosa. 1
Evidence Against Routine Use in Viral URI
The most recent high-quality evidence is clear on this issue:
The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2020) explicitly states that antihistamines show no additive effect over standard treatment in viral rhinosinusitis, based on level 1b evidence. 1
The American Academy of Otolaryngology-Head and Neck Surgery guidelines confirm that no studies have been published assessing the impact of antihistamines specifically on viral rhinosinusitis outcomes, and they are not recommended for this indication. 2
A Cochrane systematic review of 18 randomized controlled trials with 4,342 participants found that while antihistamines showed minimal short-term benefit on overall symptoms (days 1-2 only), there was no clinically significant effect on nasal obstruction, rhinorrhea, or sneezing in the mid to long term. 3
Why Antihistamines Don't Work for Viral URI
The mechanism explains the lack of efficacy:
Histamine plays no significant role in the pathogenesis of viral rhinitis symptoms. Experimental rhinovirus studies demonstrated that both oral chlorpheniramine and intranasal diphenhydramine had no significant effects on nasal symptoms or mucus production. 4
Antihistamines may actually worsen congestion by drying the nasal mucosa in patients without an allergic component to their illness. 1
When Antihistamines May Be Considered
There is one specific exception to the general recommendation:
Antihistamines may be considered only in patients with viral URI who have a documented significant allergic component contributing to their symptoms (such as concurrent allergic rhinitis), not for the viral infection itself. 1
In these cases, second-generation antihistamines are preferred over first-generation options due to reduced sedation and anticholinergic side effects. 1
Special Populations at Risk
Certain groups should particularly avoid antihistamines for viral URI:
The FDA's Nonprescription Drugs and Pediatric Advisory Committees recommend that over-the-counter antihistamines no longer be used for children below 6 years of age for viral colds. 5
The American Academy of Otolaryngology-Head and Neck Surgery recommends avoiding antihistamines in elderly patients due to increased risk of adverse effects. 1
Recommended Approach for Viral URI with Rhinorrhea
Instead of antihistamines, focus on evidence-based supportive care:
Viral rhinosinusitis is self-limiting and typically resolves without specific treatment. 1, 5
Nasal saline irrigation may improve quality of life, decrease symptoms, and decrease medication use without the risks associated with antihistamines. 1
Topical decongestants may be used for short periods (no more than 3-5 consecutive days) to reduce congestion if needed. 1
Analgesics or antipyretics can be provided for pain or fever. 2
Common Pitfall to Avoid
Do not confuse viral URI with conditions where antihistamines are effective:
Antihistamines are effective for allergic rhinitis (which comprises approximately 80% of rhinitis in children and 30% in adults), but this is a different condition from viral URI. 6
The presence of colored nasal discharge does not indicate bacterial infection or change the recommendation against antihistamines—sputum color is related to neutrophils, not bacteria. 2