The best allergy medication for a stuffy nose depends on the underlying cause and severity of your symptoms, but for most people with allergic rhinitis, intranasal corticosteroid sprays are the recommended first-line choice. Nasal congestion caused by allergies is driven by multiple inflammatory pathways — not histamine alone — which is why many people find standard antihistamines provide only limited relief. In the UK, several effective options are available over the counter, while others require a prescription. This article explains how each medication class works, what the evidence says, and how to choose the most appropriate treatment for your needs.

What Causes a Stuffy Nose in Allergic Rhinitis?

Allergic rhinitis is one of the most common chronic conditions in the UK, affecting an estimated 10–30% of people at some point in their lives (NICE CKS: Allergic rhinitis; NHS: Hay fever). When the nasal passages are exposed to an allergen — such as pollen, house dust mites, pet dander, or mould spores — the immune system mounts an exaggerated response. Immunoglobulin E (IgE) antibodies trigger mast cells lining the nasal mucosa to release inflammatory mediators, most notably histamine, leukotrienes, and prostaglandins.

This inflammatory cascade leads to the hallmark symptoms of allergic rhinitis: sneezing, itching, a runny nose (rhinorrhoea), and, importantly, nasal congestion. Congestion occurs because blood vessels within the nasal lining dilate and become more permeable, causing the tissues to swell and obstruct airflow. Unlike sneezing or itching, which are driven primarily by histamine, nasal congestion is largely mediated by multiple inflammatory pathways — including leukotrienes and other mediators — beyond histamine alone. This multi-mediator basis of congestion is a key reason why intranasal corticosteroids, which suppress a broad range of inflammatory signals, are more effective for this symptom than antihistamines alone.

Allergic rhinitis is classified as either seasonal (commonly known as hay fever, triggered by pollen) or perennial (year-round, often caused by indoor allergens such as house dust mites or pet dander). Nasal congestion tends to be more persistent and troublesome in perennial rhinitis, where ongoing allergen exposure sustains chronic mucosal inflammation. Understanding the underlying mechanism helps explain why certain medications work better than others for a stuffy nose specifically, and why a one-size-fits-all approach is rarely optimal.

Types of Allergy Medication Available for Nasal Congestion

Several classes of medication are used to manage nasal congestion associated with allergic rhinitis. Each works through a different mechanism, and their effectiveness for congestion specifically can vary considerably. The main categories include:

• Intranasal corticosteroid sprays (e.g., fluticasone, mometasone, beclometasone) — available over the counter (OTC) or on prescription depending on the product

• Oral antihistamines (e.g., cetirizine, loratadine, fexofenadine) — available OTC

• Intranasal antihistamines (e.g., azelastine) — prescription-only in the UK

• Oral and topical decongestants (e.g., pseudoephedrine, xylometazoline) — available OTC

• Leukotriene receptor antagonists (e.g., montelukast) — prescription-only; reserved for selected patients, particularly those with coexisting asthma, after first-line therapy has been optimised

• Intranasal anticholinergics (e.g., ipratropium) — prescription-only; primarily used for rhinorrhoea rather than congestion

• Allergen immunotherapy — available via specialist referral

Each of these options has a distinct pharmacological profile, evidence base, and suitability depending on the severity and pattern of symptoms. For mild, intermittent symptoms, a single agent may suffice. For moderate-to-severe or persistent congestion, combination therapy is often more effective.

It is worth noting that not all allergy medications are equally effective at relieving a stuffy nose. Oral antihistamines, for example, are highly effective for sneezing and itching but have limited impact on nasal congestion, as congestion is driven by multiple inflammatory mediators beyond histamine alone. Selecting the most appropriate medication therefore requires consideration of the patient's predominant symptoms, the pattern of allergen exposure, any coexisting conditions, and individual tolerability.

Important safety note — montelukast: The MHRA has issued a Drug Safety Update advising that montelukast is associated with neuropsychiatric reactions, including sleep disturbances, depression, anxiety, and suicidal thoughts. Patients and carers should be made aware of these risks, and the medicine should be stopped and medical advice sought promptly if such symptoms occur.

Reporting side effects: Suspected adverse reactions to any medicine can be reported to the MHRA via the Yellow Card Scheme at yellowcard.mhra.gov.uk.

Nasal Corticosteroid Sprays: The First-Line Recommendation

According to NICE CKS (Allergic rhinitis) and NHS clinical guidance, intranasal corticosteroid sprays are the first-line treatment for allergic rhinitis, particularly when nasal congestion is a prominent symptom. These sprays work by reducing local inflammation within the nasal mucosa. They suppress the release of multiple inflammatory mediators — including histamine, leukotrienes, and cytokines — thereby addressing the full spectrum of nasal symptoms more comprehensively than antihistamines alone.

Commonly used intranasal corticosteroids in the UK include:

• Fluticasone propionate (e.g., Flixonase) — available over the counter as a pharmacy medicine

• Beclometasone dipropionate (e.g., Beconase) — available over the counter as a pharmacy medicine

• Mometasone furoate (e.g., Nasonex Allergy Control) — available over the counter as a pharmacy medicine (50 micrograms/spray); higher-dose or alternative formulations may be prescription-only

• Fluticasone furoate (e.g., Avamys) — prescription-only

These sprays are generally well tolerated. The most common side effects are local and include nasal dryness, irritation, and occasional minor nosebleeds (epistaxis). Systemic absorption is minimal at recommended doses, making them suitable for regular use. Patients should use the lowest effective dose, and prolonged use in children should be discussed with a healthcare professional in line with individual product SmPCs. Patients should be advised to use the correct technique — directing the spray towards the outer wall of the nostril rather than the nasal septum — to minimise the risk of irritation and nosebleeds.

Crucially, intranasal corticosteroids take several days to reach full effect, so patients should be counselled to use them regularly and not to expect immediate relief. For seasonal allergic rhinitis, starting treatment at least two weeks before the anticipated pollen season is recommended to establish adequate anti-inflammatory control before symptoms begin (NICE CKS: Allergic rhinitis; NHS: Hay fever).

Suspected side effects from intranasal corticosteroids should be reported via the MHRA Yellow Card Scheme at yellowcard.mhra.gov.uk.

Antihistamines and Decongestants: What the Evidence Says

Oral antihistamines are widely used and readily available without prescription. Second-generation antihistamines — such as cetirizine, loratadine, and fexofenadine — are preferred over first-generation agents (e.g., chlorphenamine) because they cause significantly less sedation and have a longer duration of action. They work by competitively blocking H1 histamine receptors, thereby reducing sneezing, itching, and rhinorrhoea. However, clinical evidence consistently shows that oral antihistamines provide only modest relief of nasal congestion, as congestion is not primarily histamine-mediated. Note that fexofenadine is available OTC as a pharmacy medicine at 120 mg for hay fever symptoms; the 180 mg strength is prescription-only.

Intranasal antihistamines, such as azelastine (prescription-only in the UK), act more rapidly than oral formulations and may offer slightly better congestion relief due to local anti-inflammatory effects beyond simple H1 blockade. A combination intranasal spray containing both azelastine and fluticasone propionate (Dymista, prescription-only) has demonstrated superior efficacy for nasal congestion compared with either agent alone in clinical trials, and is licensed in the UK for moderate-to-severe allergic rhinitis in adults and adolescents aged 12 years and over.

Decongestants — both oral (pseudoephedrine) and topical (xylometazoline, oxymetazoline) — work by stimulating alpha-adrenergic receptors in nasal blood vessels, causing vasoconstriction and rapid reduction in mucosal swelling. They can provide fast, effective short-term relief of congestion. However, important cautions apply:

• Topical decongestants (e.g., xylometazoline 0.1% for adults) should not be used for more than five to seven consecutive days due to the risk of rebound congestion (rhinitis medicamentosa). Lower-strength formulations (e.g., 0.05%) may be licensed for use in children from 6 years of age — always follow the individual product SmPC for licensed age ranges and doses.

• Oral decongestants (e.g., pseudoephedrine) are contraindicated in patients with severe or uncontrolled hypertension, serious cardiovascular disease, or hyperthyroidism, and in those who have taken monoamine oxidase inhibitors (MAOIs) within the preceding 14 days. Caution is also advised in patients with glaucoma or prostatic hypertrophy. Most oral pseudoephedrine products are not recommended for children under 12 years of age — check the individual product licence.

• The MHRA and European Medicines Agency (EMA/PRAC) have issued a safety communication advising that pseudoephedrine is associated with rare but serious neurological adverse effects, including posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS). Patients should use the lowest effective dose for the shortest possible time and seek immediate medical attention if they experience a sudden severe headache, visual disturbances, confusion, or seizures.

Decongestants are best reserved for short-term relief during acute flare-ups rather than as a long-term management strategy. Suspected adverse reactions should be reported via the MHRA Yellow Card Scheme at yellowcard.mhra.gov.uk.

Choosing the Right Treatment: Prescription vs Over-the-Counter Options

Many effective allergy medications for a stuffy nose are now available over the counter (OTC) in the UK, making it easier for patients to self-manage mild-to-moderate symptoms without a GP appointment. Pharmacists play a central role in guiding appropriate OTC selection and can advise on suitability based on individual circumstances.

Over-the-counter pharmacy medicine options suitable for nasal congestion in allergic rhinitis include:

• Intranasal corticosteroids: beclometasone dipropionate (e.g., Beconase), fluticasone propionate (e.g., Flixonase), mometasone furoate 50 micrograms/spray (e.g., Nasonex Allergy Control)

• Second-generation oral antihistamines: cetirizine, loratadine, fexofenadine 120 mg (for hay fever)

• Short-term topical decongestants: xylometazoline (e.g., Otrivine) — for up to five to seven days only

Note: budesonide nasal spray (e.g., Rhinocort Aqua) is a separate corticosteroid product and should not be confused with mometasone.

For patients with moderate-to-severe or persistent symptoms that do not respond adequately to OTC treatments, a GP can prescribe alternative dose regimens, combination products (such as azelastine/fluticasone — Dymista, prescription-only), or leukotriene receptor antagonists such as montelukast (prescription-only). Montelukast has limited evidence for nasal congestion specifically and is most useful in patients who also have coexisting asthma; prescribers and patients should be aware of the MHRA neuropsychiatric safety warning associated with this medicine (see above).

When selecting a treatment, the following factors should be considered:

• Predominant symptoms: congestion alone versus a full symptom complex including sneezing, itching, and rhinorrhoea

• Pattern of rhinitis: seasonal versus perennial

• Coexisting conditions: asthma, cardiovascular disease, pregnancy, or breastfeeding

• Age: some medications are not licensed for use in young children — always check the product SmPC

• Tolerability: sedation risk with older antihistamines; neuropsychiatric risk with montelukast

• Legal status: confirm whether a product is a pharmacy medicine (P) or prescription-only medicine (POM) before recommending

For most adults with allergic rhinitis and nasal congestion, a regular intranasal corticosteroid spray — used consistently and with correct technique — represents the most evidence-based and cost-effective starting point, whether obtained OTC or on prescription (NICE CKS: Allergic rhinitis; BNF).

When to Seek Further Advice From a GP or Pharmacist

For many people, allergic rhinitis and nasal congestion can be effectively managed with OTC treatments and lifestyle measures such as allergen avoidance and saline nasal irrigation. However, there are circumstances in which it is important to seek professional advice from a pharmacist or GP rather than continuing to self-treat.

Consult a pharmacist if:

• You are unsure which medication is most appropriate for your symptoms

• You are taking other medications and wish to check for interactions

• Symptoms are new and you have not previously been diagnosed with allergic rhinitis

• You are pregnant, breastfeeding, or selecting treatment for a child

• You have been using a topical decongestant nasal spray for more than five to seven days and are concerned about rebound congestion

See a GP if:

• Symptoms are not adequately controlled after two to four weeks of regular, correctly used intranasal corticosteroid treatment, or after four to six weeks of appropriate OTC treatment overall

• Nasal congestion is severe, persistent, or significantly affecting quality of life, sleep, or work

• You develop symptoms suggestive of sinusitis (facial pain or pressure, or purulent nasal discharge)

• There is unilateral nasal obstruction (blockage on one side only), unexplained or recurrent nosebleeds, persistent blood-stained or purulent discharge, facial swelling, visual symptoms, or loss of smell — these require prompt assessment to exclude other causes

• You have coexisting asthma that is poorly controlled

• You experience neuropsychiatric symptoms (such as mood changes, sleep disturbance, or anxiety) that you suspect may be related to a medicine you are taking

In cases of severe or refractory allergic rhinitis, a GP may refer to an allergy specialist or ENT (ear, nose and throat) consultant. Specialist options include allergen immunotherapy (desensitisation), which can modify the underlying immune response and provide long-term symptom relief. NICE has issued Technology Appraisals supporting the use of sublingual immunotherapy tablets for grass pollen allergic rhinitis (e.g., Grazax, Oralair) and house dust mite allergic rhinitis (e.g., Acarizax) in selected patients who have not responded adequately to standard pharmacotherapy.

Early and appropriate treatment of nasal congestion in allergic rhinitis not only improves daily comfort but can also reduce the risk of associated complications, including sinusitis, sleep disturbance, and worsening of coexisting asthma.

Suspected adverse reactions to any medicine used for allergic rhinitis should be reported to the MHRA via the Yellow Card Scheme at yellowcard.mhra.gov.uk.

Frequently Asked Questions