What is the first‑line treatment for an otherwise healthy adult with a runny and stuffy nose, without drug allergies, hypertension, glaucoma, thyroid disease, or chronic nasal problems?

First-Line Treatment for Runny and Stuffy Nose

For an otherwise healthy adult with a runny and stuffy nose, start with intranasal corticosteroid spray (fluticasone, mometasone, or budesonide) 2 sprays per nostril once daily, combined with nasal saline irrigation. 1

Understanding the Likely Diagnosis

Your symptoms suggest either viral rhinitis (common cold) or allergic rhinitis, and the treatment approach differs slightly:

• If symptoms have been present for less than 7 days, you most likely have viral rhinitis, which is self-limiting and typically resolves within 10-14 days 2
• If symptoms are recurrent, seasonal, or persistent beyond 2 weeks, allergic rhinitis is more likely 1
• The distinction matters less for initial treatment because intranasal corticosteroids work for both conditions 1

First-Line Treatment Approach

Intranasal Corticosteroids (Most Important)

• Intranasal corticosteroids are the single most effective medication for both runny nose and nasal congestion, addressing all major symptoms comprehensively 1
• Start immediately with fluticasone, mometasone, budesonide, or triamcinolone at 200 mcg daily (2 sprays per nostril once daily) 1
• These medications are superior to oral antihistamines for nasal congestion, which antihistamines barely address 1, 3
• Critical technique: Direct the spray away from the nasal septum toward the outer wall of the nose to prevent mucosal erosions and potential septal perforation 1
• Expect modest symptom improvement within 2-3 days, with full benefit by 1-2 weeks 4

Nasal Saline Irrigation (Essential Adjunct)

• Use nasal saline irrigation 2-3 times daily to mechanically clear secretions and reduce congestion 1, 2
• This simple measure provides significant relief and works synergistically with intranasal corticosteroids 1
• Saline is beneficial for both viral and allergic rhinitis 4, 1

Symptomatic Relief Options

• For pain, headache, or fever: Use acetaminophen or ibuprofen as needed 4, 2
• For severe congestion in the first 3 days only: You may add oxymetazoline (Afrin) nasal spray for a maximum of 3 days 1, 5
  • Never use topical decongestants beyond 3-5 days because prolonged use causes rebound congestion (rhinitis medicamentosa), making your symptoms worse 1, 2

What NOT to Do

• Do not start with oral antihistamines (loratadine, cetirizine, fexofenadine) as first-line therapy because they have minimal effect on nasal congestion 1, 3
• Do not take antibiotics for a runny and stuffy nose—they are completely ineffective for viral illness and provide no benefit for uncomplicated rhinitis 4, 2
• Avoid oral decongestants (pseudoephedrine, phenylephrine) if you develop hypertension, heart disease, anxiety, or prostate problems in the future 1, 6
• Do not use first-generation antihistamines (diphenhydramine, chlorpheniramine) because they cause significant sedation and performance impairment without effectively treating congestion 3

When to Add or Switch Medications

If Intranasal Corticosteroid Alone Is Insufficient After 1-2 Weeks

• Add an intranasal antihistamine (azelastine) to your intranasal corticosteroid for greater symptom reduction 1
• This combination is more effective than either medication alone for moderate to severe symptoms 1

If Runny Nose (Rhinorrhea) Is Your Dominant Symptom

• Add ipratropium bromide nasal spray specifically for rhinorrhea, as it is highly effective for watery discharge 1
• Ipratropium works through a different mechanism (anticholinergic) and complements intranasal corticosteroids 1

If You Prefer Oral Medication Despite Lower Efficacy

• Second-generation oral antihistamines may be used if you refuse nasal sprays, but understand they will not adequately treat congestion 1, 3
• Choose fexofenadine (truly non-sedating) or loratadine (non-sedating at recommended doses) over cetirizine, which causes mild drowsiness in 13.7% of patients 3
• Do not add oral antihistamines to intranasal corticosteroids routinely, as multiple high-quality trials show no additional benefit 1

When to Suspect Allergic Rhinitis and Consider Long-Term Management

• If symptoms recur seasonally, persist beyond 2 weeks, or include itching and sneezing, you likely have allergic rhinitis 1
• Continue intranasal corticosteroids long-term for persistent allergic rhinitis 1
• Consider referral to an allergist for allergen testing and possible immunotherapy if symptoms remain inadequately controlled despite optimal medication use 1
• Allergen immunotherapy is the only treatment that modifies the natural history of allergic rhinitis and may prevent asthma development 1

Common Pitfalls to Avoid

• Stopping intranasal corticosteroids too early: These medications require 1-2 weeks for full effect; don't abandon them after 2-3 days 4
• Using topical decongestants beyond 3 days: This creates a vicious cycle of worsening rebound congestion requiring more medication 1, 2
• Relying on oral antihistamines for congestion: They simply don't work for this symptom; you need intranasal corticosteroids 1, 3
• Improper spray technique: Aiming toward the septum instead of the outer nasal wall increases the risk of nosebleeds and septal damage 1

Red Flags Requiring Medical Reevaluation

• Symptoms persisting beyond 10 days without any improvement 4, 2
• "Double worsening"—initial improvement followed by worsening within 10 days, suggesting bacterial sinusitis 2
• Severe unilateral facial pain with purulent nasal discharge 2
• High fever, severe headache, or visual changes 2