A persistent or severe cough that doesn't respond to over-the-counter remedies signals the need for a professional medical evaluation. The most effective treatment for a severe cough addresses its root cause, which can range from a respiratory infection to a chronic condition like asthma or gastroesophageal reflux disease (GERD). A doctor will first aim to diagnose the underlying issue and then prescribe the most appropriate medication. These prescriptions can include suppressants, expectorants, and drugs that treat the specific disease triggering the cough.
Targeted Prescription Medications Based on Cause
When a severe cough is a symptom of another condition, a doctor will focus on treating that primary problem. Medications in this category are highly specific and not general cough remedies.
Allergies and Postnasal Drip
Postnasal drip is a common cause of chronic coughing, occurring when excess mucus from the nasal passages trickles down the back of the throat.
- Antihistamines: Prescription-strength antihistamines like azelastine or hydroxyzine can reduce the allergic response that leads to postnasal drip.
- Nasal corticosteroids: Steroid nasal sprays, such as fluticasone, can decrease inflammation in the nasal passages, helping to control postnasal drip.
Asthma or COPD
For a severe cough related to inflammatory lung conditions, treatment focuses on reducing airway inflammation and opening air passages.
- Inhaled corticosteroids: These are the primary treatment for asthma-related coughs, including cough-variant asthma.
- Bronchodilators: Rescue inhalers like albuterol are used for quick relief of an asthma-induced cough and wheezing.
- Oral steroids: In cases of severe exacerbations, a short course of oral corticosteroids, like prednisone, may be prescribed to reduce significant inflammation.
Gastroesophageal Reflux Disease (GERD)
GERD can cause a severe cough when stomach acid backs up into the esophagus and triggers the cough reflex.
- Proton Pump Inhibitors (PPIs): Medications such as omeprazole and pantoprazole reduce stomach acid production and are a common treatment for GERD-related cough.
- H2 blockers: Famotidine is another option that can help block acid production.
Bacterial Infections
If a severe cough is caused by a bacterial infection, such as bacterial pneumonia or sinusitis, antibiotics will be prescribed to eliminate the infection. It is important to remember that antibiotics are ineffective against viral infections.
Refractory Chronic Cough
When no underlying cause can be identified, the cough is considered refractory. In these instances, doctors might explore alternative approaches.
- Neuromodulators: Gabapentin, a medication typically used for nerve pain, has been shown to improve cough-specific quality of life in patients with refractory chronic cough.
- Speech pathology: Behavioral cough suppression therapy, often delivered by a speech pathologist, can also be an effective strategy.
Potent Cough Suppressants and Expectorants
In addition to treating the underlying cause, doctors may prescribe specific medications to manage the cough reflex directly, especially for short-term relief of debilitating symptoms.
Benzonatate (Tessalon Perles)
Benzonatate is a non-narcotic prescription antitussive that numbs the stretch receptors in the lungs and airways, which helps to suppress the cough reflex. It is important to swallow the capsule whole, as chewing or dissolving it can cause numbness in the mouth and throat, leading to choking. Due to a risk of fatal overdose, it is not recommended for children under 10.
Opioid-Based Cough Syrups
For severe, unrelenting coughs in adults, opioid-based cough syrups containing codeine or hydrocodone may be prescribed. These are controlled substances and come with significant risks, including potential for addiction and impaired coordination.
- Codeine/Guaifenesin: This combination medication suppresses the cough reflex with codeine while also thinning mucus with guaifenesin.
- Hydrocodone/Guaifenesin: Similar to the codeine combination, this works to both suppress the cough and clear mucus.
Note: The FDA does not recommend these controlled substances for children or teenagers under 18.
Lifestyle and Home Remedies
Alongside prescription medication, lifestyle modifications and home remedies can provide significant relief for a severe cough.
- Stay hydrated: Drinking plenty of fluids helps thin mucus, making it easier to clear from the airways.
- Use a humidifier: A cool-mist humidifier adds moisture to the air, which can soothe irritated airways and help reduce coughing.
- Elevate your head: Sleeping with your head elevated on extra pillows can help prevent mucus from pooling in the throat and reduce nighttime coughing, especially for those with postnasal drip or GERD.
- Avoid irritants: Steer clear of tobacco smoke, dust, and other allergens that can trigger or worsen a cough. If you smoke, quitting is one of the most effective steps to manage a chronic cough.
Comparison of Common Prescription Cough Treatments
| Medication Category | Mechanism of Action | Common Use Cases | Key Considerations |
|---|---|---|---|
| Benzonatate (Tessalon Perles) | Numbing the cough reflex peripherally in the lungs and airways | Dry, non-productive cough, often following an infection | Non-narcotic, must be swallowed whole, not for children under 10, potential for severe side effects if chewed |
| Opioid-Based Syrups (Codeine/Hydrocodone) | Suppressing the cough center in the brain | Severe, short-term cough in adults when other options fail | Controlled substances, high risk of dependence and side effects, not recommended for children |
| Inhaled Corticosteroids | Reducing inflammation in the airways | Cough due to asthma, COPD, or prolonged post-viral inflammation | Regular use required for control, fewer systemic side effects than oral steroids |
| Proton Pump Inhibitors (PPIs) | Reducing stomach acid production | Cough caused by gastroesophageal reflux (GERD) | May take several weeks to see full effect, often combined with lifestyle changes |
| Gabapentin | Neuromodulating central cough reflex sensitivity | Refractory or unexplained chronic cough in adults | Used off-label, can cause dizziness and fatigue, not a first-line treatment |
| Antibiotics | Killing bacterial infections | Cough caused by a diagnosed bacterial infection (e.g., bacterial bronchitis, sinusitis) | Only effective for bacterial infections, not viruses, overuse contributes to antibiotic resistance |
Conclusion
When over-the-counter treatments are not sufficient for a severe cough, consulting a doctor is the next step. A physician can accurately diagnose the underlying cause, which is the most critical factor in determining the correct course of action. Prescriptions can range from treating infections with antibiotics to managing chronic conditions like asthma and GERD with specialized medications. Potent cough suppressants like benzonatate and, in rare cases, opioid-based syrups are reserved for specific situations and carry their own set of risks and precautions. Lifestyle adjustments and home remedies can also provide important symptomatic relief. Always follow a healthcare professional's guidance for severe cough treatment to ensure safety and effectiveness. The American College of Chest Physicians (CHEST) offers extensive guidelines on cough management for professionals, emphasizing a thorough diagnostic approach.
