Management of Acute Cough and Scratchy Throat in Healthy Adults
For an otherwise healthy adult with cough and scratchy throat, the simplest and most cost-effective first-line treatment is honey and lemon, as acute viral upper respiratory infections are almost invariably benign and self-limited. 1
Initial Assessment
This presentation is most consistent with an acute viral upper respiratory tract infection (common cold), which typically resolves within 3 weeks without specific treatment. 1, 2
- Acute cough lasting less than 3 weeks is most commonly caused by a self-limited viral upper respiratory tract infection 2
- Viral upper respiratory infections transiently increase cough reflex sensitivity, which explains the persistent irritation and cough 3
- Physical examination findings are typically minimal or absent in uncomplicated viral upper respiratory infections 1
Evidence-Based Treatment Approach
First-Line: Non-Pharmacological Management
Honey and lemon mixtures are as effective as pharmacological treatments without any adverse effects and should be recommended first. 4
- Acute viral cough can be distressing and cause significant morbidity despite being benign 1
- Simple voluntary suppression of cough may be sufficient to reduce cough frequency through central modulation of the cough reflex 1
- Simple drinks and linctuses likely work through this central modulation mechanism 1
Second-Line: Pharmacological Options (If Needed)
If symptoms are particularly bothersome and non-pharmacological measures are insufficient, consider:
Dextromethorphan 30-60 mg is the safest and most effective pharmacological option for dry cough suppression. 4
- Standard over-the-counter dosing (15-30 mg) is often subtherapeutic 4
- Maximum cough reflex suppression occurs at 60 mg and can be prolonged 1
- Maximum daily dose should not exceed 120 mg 4
- Use should be limited to short-term relief only (typically less than 7 days) 4
- Check combination products carefully, as some contain acetaminophen or other ingredients that can accumulate to toxic levels with higher dextromethorphan doses 4
For nocturnal cough specifically, first-generation antihistamines with sedative properties may be added. 1
- These suppress cough but also cause drowsiness, making them suitable specifically for nighttime use 1
- Exercise caution due to potential anticholinergic side effects including dry mouth, urinary retention, and increased intraocular pressure in glaucoma patients 5
Menthol by inhalation provides acute, short-lived cough suppression. 1
- May be prescribed as menthol crystals or proprietary capsules 1
What NOT to Use
Codeine or pholcodine should never be prescribed, as these opioid antitussives have no greater efficacy than dextromethorphan but carry a much greater adverse side effect profile. 1, 4
Antibiotics have no role in viral upper respiratory infections and should not be used in patients with less severe presentations. 5
- The upper respiratory tract may become susceptible to bacterial infection as a result of viral infections, but this does not justify empiric antibiotic use 6
When to Reassess
If cough persists beyond 3 weeks, discontinue antitussive therapy and pursue a full diagnostic workup for chronic cough. 4
- Cough lasting 3-8 weeks is classified as subacute and commonly has a postinfectious origin 2
- Cough lasting longer than 8 weeks is classified as chronic and requires systematic evaluation for underlying causes including upper airway cough syndrome, asthma, gastroesophageal reflux disease, or medication effects 1, 5, 2
Critical Pitfalls to Avoid
- Never prescribe opioid-based antitussives (codeine, pholcodine) for acute viral cough 1, 4
- Never prescribe antibiotics for uncomplicated viral upper respiratory infections 5
- Never use subtherapeutic doses of dextromethorphan (15-30 mg may be insufficient) 4
- Never suppress productive cough, as secretion clearance is beneficial 4
- Never continue symptomatic treatment beyond 3 weeks without reassessing for chronic causes 4, 2