Post-Viral Upper Airway Cough Syndrome (Postnasal Drip)
You have post-viral upper airway cough syndrome (UACS), previously called postnasal drip syndrome, which is the most common cause of persistent cough after a cold and requires treatment with a first-generation antihistamine/decongestant combination. 1, 2
Understanding Your Condition
Your 2-week history of nighttime cough and nasal congestion following an upper respiratory infection fits the classic pattern of post-viral UACS. 1 The common cold directly irritates upper airway structures and triggers an inflammatory response that can persist for weeks after the initial viral infection resolves. 1 Approximately 25% of patients continue to have symptoms of cough, postnasal drip, and throat clearing at 2 weeks after a cold, and this can become self-perpetuating unless interrupted with active treatment. 1
The nighttime worsening of your cough is explained by gravity-driven drainage of nasal and sinus secretions into the hypopharynx when lying down, which directly irritates cough receptors. 2
First-Line Treatment
Start a first-generation antihistamine/decongestant combination immediately (such as brompheniramine with sustained-release pseudoephedrine, or chlorpheniramine with sustained-release pseudoephedrine). 1, 2 This combination has proven efficacy in both acute and chronic cough associated with the common cold. 2
- Dosing strategy: To minimize sedation, start with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy. 2
- Expected response: Most patients see improvement within days to 2 weeks of initiating therapy. 2
- Common side effects: Dry mouth and transient dizziness are typical; more serious effects include insomnia, urinary retention, jitteriness, tachycardia, and worsening hypertension. 2
Important: Newer-generation non-sedating antihistamines (like loratadine, cetirizine, or fexofenadine) are ineffective for this condition and should not be used. 1, 2 The older antihistamines work because of their anticholinergic properties, which the newer agents lack. 2
When to Add Intranasal Corticosteroids
If your symptoms do not improve after 1-2 weeks with the antihistamine/decongestant combination alone, add an intranasal corticosteroid (such as fluticasone 100-200 mcg daily, 1-2 sprays per nostril). 2, 3 A full 1-month trial is necessary to assess response. 2
Adjunctive Measures
- Nasal saline irrigation (high-volume, 150 mL) is more effective than saline spray because it mechanically removes secretions and improves mucociliary function. 2
- Sleep with the head of bed elevated to reduce gravitational drainage of secretions. 4
- Adequate hydration and warm facial packs provide supportive relief. 4
What NOT to Do
Do not take antibiotics. 1, 3 Your symptoms are due to viral inflammation, not bacterial infection. Even purulent (yellowish-green) nasal discharge does not indicate bacterial infection during the first week after a cold. 1, 2 Antibiotics should not be prescribed during the first week of symptoms, even with purulent discharge or sinus imaging abnormalities, because these findings are indistinguishable from viral rhinosinusitis. 1, 2
Do not use topical nasal decongestants (like oxymetazoline or xylometazoline) for more than 3-5 consecutive days due to the risk of rebound congestion (rhinitis medicamentosa). 2
When to Reassess
Return for re-evaluation if:
- Symptoms persist beyond 2 weeks despite adequate treatment with antihistamine/decongestant combination. 2, 3
- Fever develops, hemoptysis occurs, or symptoms worsen. 3, 4
- Cough extends beyond 8 weeks, at which point it should be reclassified as chronic cough and systematically evaluated for asthma and gastroesophageal reflux disease. 2, 3, 4
Common Pitfall to Avoid
Approximately 20% of patients have "silent" postnasal drip with no obvious nasal symptoms yet still respond to UACS-directed treatment. 2 The diagnosis is confirmed by response to therapy, not by physical examination findings alone. 2, 3