What over‑the‑counter medications can I take for nasal or sinus congestion as an otherwise healthy adult?

Over-the-Counter Medications for Head Congestion

For nasal congestion relief, use oral pseudoephedrine (60 mg every 4-6 hours) or a topical nasal decongestant like oxymetazoline for no more than 3-5 days, combined with nasal saline irrigation and intranasal corticosteroids for optimal symptom control. 1, 2

First-Line Symptomatic Relief Options

Nasal Saline Irrigation

• Recommended as a primary treatment for relieving congestion and removing thick mucus that is difficult to expel 1
• Safe for daily use without risk of rebound congestion 1
• Can be used in combination with all other therapies 1

Intranasal Corticosteroids

• May reduce symptoms after 15 days of use, though the benefit is modest (approximately 14 people must use them for 1 person to improve) 1
• Side effects include headache, nasal itching, and nosebleeds 1
• More effective than oral antihistamines for nasal congestion 1
• Appropriate for both viral and bacterial causes of congestion 1

Analgesics for Associated Symptoms

• Acetaminophen (paracetamol) may help relieve nasal obstruction and rhinorrhea but does not improve other cold symptoms 1
• NSAIDs (ibuprofen) significantly benefit headache, ear pain, and muscle pain, and improve sneezing scores, though they do not reduce total symptom duration 1
• Both are recommended for pain and fever relief associated with sinus congestion 1

Decongestant Options

Topical Nasal Decongestants (Preferred for Severe Acute Congestion)

• Oxymetazoline or xylometazoline nasal sprays are superior to oral decongestants for reducing nasal and sinus mucosal congestion 2
• Provide faster and more intense relief than oral agents 3
• Critical limitation: Must not be used for more than 3-5 consecutive days due to risk of rebound congestion (rhinitis medicamentosa) 1, 2
• Recent evidence suggests no rebound congestion occurs with oxymetazoline used up to 7 days at recommended doses (up to 400 μg total daily dose), with some studies showing safety up to 4 weeks 4
• Despite newer evidence, guidelines still recommend the 3-5 day limit as a safety precaution 2, 5

Oral Decongestants

• Pseudoephedrine (60 mg every 4-6 hours) is the most effective oral decongestant and may provide a small positive effect on subjective nasal congestion 1, 2, 6
• Significantly more effective than phenylephrine due to better oral bioavailability 2, 3
• Phenylephrine should be avoided as it undergoes extensive first-pass metabolism and is not bioavailable at currently recommended oral doses 2, 3
• Can be used for longer duration than topical agents without rebound congestion risk 1

Important Decongestant Precautions

• Use with caution in patients with hypertension, arrhythmias, coronary artery disease, cerebrovascular disease, hyperthyroidism, and glaucoma 2
• Oral decongestants cause small increases in systolic blood pressure (0.99 mmHg) and heart rate (2.83 beats/min) 2
• Avoid during first trimester of pregnancy due to reported fetal heart rate changes 2

What NOT to Use

Antihistamines

• Have no role in symptomatic relief of congestion in non-allergic patients and may worsen congestion by drying nasal mucosa 1, 2
• Should not be used routinely for infectious causes of congestion 1
• Only consider if significant allergic component is present (sneezing, itching, known allergies) 1

Guaifenesin

• No evidence supports its use for relieving nasal congestion, despite being marketed to "loosen" secretions 1, 2

Oral Corticosteroids

• Should not be used routinely for simple nasal congestion due to side effects without proven benefit 1

Practical Treatment Algorithm

For mild to moderate congestion:

1. Start with nasal saline irrigation (can use multiple times daily) 1
2. Add intranasal corticosteroid spray for sustained relief over days to weeks 1, 2
3. Consider oral pseudoephedrine if additional relief needed 2

For severe acute congestion:

1. Use topical decongestant (oxymetazoline) for rapid relief, maximum 3-5 days 2
2. Simultaneously start nasal saline irrigation and intranasal corticosteroid 2
3. Transition to oral pseudoephedrine if congestion persists beyond 3-5 days 2

For associated symptoms:

• Add acetaminophen or ibuprofen for pain, fever, or headache 1

Common Pitfalls to Avoid

• Do not use topical decongestants beyond 3-5 days without a prolonged drug-free interval, as this leads to rhinitis medicamentosa 1, 2, 5
• Do not substitute phenylephrine for pseudoephedrine orally, as phenylephrine lacks efficacy 2, 3
• Do not add antihistamines unless allergic symptoms are clearly present (sneezing, itching, watery eyes), as they can worsen congestion in infectious rhinitis 1, 2
• Screen for cardiovascular contraindications before recommending any decongestant 2