What treatments are effective for nasal congestion?

Treatment of Nasal Congestion (Stuffy Nose)

Intranasal corticosteroid sprays are the single most effective treatment for nasal congestion and should be your first-line therapy, providing superior relief compared to all other medication classes. 1, 2

First-Line Treatment Approach

Start with intranasal corticosteroids as they are the most effective monotherapy for controlling all nasal symptoms including congestion, whether the cause is allergic or nonallergic rhinitis. 1, 2

• These medications work on all four major symptoms: sneezing, itching, rhinorrhea, and especially nasal congestion 1
• Onset of action typically occurs within 12 hours, though full benefit may take several days 1
• They have minimal systemic side effects when used at recommended doses 1
• Local side effects are minimal if you direct the spray away from the nasal septum (to avoid irritation and bleeding) 1

Add saline nasal irrigation as highly effective adjunctive therapy with essentially no side effects. 1, 2

• Use isotonic (normal) saline rather than hypertonic solutions, as isotonic is more effective and better tolerated 1
• This improves mucous clearance and enhances ciliary activity 2
• Can be used multiple times daily without concern for rebound effects 1

Second-Line Options When Additional Relief Needed

If allergic rhinitis is contributing, add a second-generation antihistamine (desloratadine, fexofenadine, or loratadine). 1, 2

• Second-generation agents are strongly preferred over first-generation antihistamines to avoid sedation and performance impairment 1
• Newer antihistamines like desloratadine and fexofenadine do provide some relief of nasal congestion, contrary to older agents 3, 4
• Intranasal antihistamines (like azelastine) have a clinically significant effect on congestion and work rapidly 1, 2

For immediate short-term relief, oral decongestants (pseudoephedrine) can be added. 1, 5

• These effectively reduce nasal congestion but cause side effects including insomnia, irritability, and palpitations 1
• Use with extreme caution in patients with hypertension, cardiovascular disease, glaucoma, or hyperthyroidism 1, 2
• The combination of oral antihistamine plus oral decongestant provides more effective congestion relief than antihistamine alone 1

Critical Pitfalls to Avoid

Never use topical nasal decongestant sprays (oxymetazoline, phenylephrine) for more than 3 days. 1, 2

• While recent evidence suggests they may be safe for up to 7-10 days, the traditional 3-day limit remains the safest recommendation to avoid rhinitis medicamentosa (rebound congestion) 6, 7
• Some patients develop rebound congestion in as little as 3 days, while others may tolerate longer use—but you cannot predict which patients 1
• If rhinitis medicamentosa develops, immediately discontinue the topical decongestant and treat with intranasal or even systemic corticosteroids 1, 6

Do not rely on antihistamines alone for nasal congestion—they are much less effective for congestion than for other nasal symptoms. 1, 2

Do not discontinue intranasal corticosteroids too early when symptoms improve, as this leads to recurrence. 2

Treatment Based on Underlying Cause

For allergic rhinitis: Intranasal corticosteroids first, add second-generation antihistamine if needed 1, 2

For vasomotor/nonallergic rhinitis: Intranasal corticosteroids or intranasal antihistamines are effective; oral antihistamines are NOT effective 1

For rhinorrhea-predominant symptoms: Add intranasal anticholinergic (ipratropium) to your regimen, though it does not help congestion itself 1

For acute viral upper respiratory infection/sinusitis: Use analgesics, saline irrigation, and consider short-term topical decongestants (≤3 days) or intranasal corticosteroids for symptomatic relief 1