Given how much space is dedicated to them in the pharmacy aisles, it may surprise you to know that most over-the-counter cold medications don’t really work. Considering the amount of money we spend on these products every year — estimated at $2.9 billion in the U.S. — their status as a pharmaceutical mainstay in most medicine cabinets is both baffling and economically counterproductive. 

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To be clear, the “common cold” is not a real disease. It is a catch-all term for the many viruses swirling around us at any given time. Most adults get two to three such infections per year, while kids tend to get five to seven. Whereas bacteria can be treated with antibiotics, viral infections usually have no specific treatment and must run their course. Antivirals for viruses like influenza and COVID-19 exist, but their benefit is modest, and they are not widely used.

Labos: The cold hard truth about cold medications Back to video

None of the over-the-counter cold medications for sale at pharmacies are cures. They are products to alleviate symptoms and make you feel less crummy while your body oozes and aches. Of the panoply of products on the market, the most widely used are the common analgesics like acetaminophen (Tylenol), ibuprofen (Advil) and naproxen (Aleve).

Acetaminophen is generally preferred over the other two because anti-inflammatories like ibuprofen and naproxen increase your blood pressure, can cause stomach ulcers, may potentially affect your kidneys and are associated with a higher risk of heart attack and stroke. If used briefly in younger patients, the risk is probably very low, but in older patients with pre-existing medical problems, we try to minimize their use. 

While they don’t treat the virus, they can alleviate a headache, lower a fever and mollify the pains and muscle aches that come with being sick. But they do not shorten the duration of symptoms or deal with other symptoms, like a cough. 

Post-viral coughs are remarkably stubborn. Practice guidelines suggest not treating them at all because the track record of most cough syrups is so poor.

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The most common ingredient in modern cough syrups is dextromethorphan. In clinical trials, its benefit has been inconsistent and small even at the best of times. It is also associated with more side-effects and is generally felt not to be worth the added cost. Older cough medications like codeine are rarely found in cough syrups these days. Data eventually showed that codeine was no better than placebo and had many side-effects. 

Because the congestion of a runny nose is a common cold complaint, most cold tablets are combo pills that contain an oral decongestant. The problem is that oral decongestants have a small but clinically insignificant benefit, which ultimately led the Food and Drug Administration to propose phasing out their use.

There is some modest benefit when decongestants are used as a nasal spray, but after three days of continuous use, a tolerance develops and you must continue using them or suffer a rebound and worsening of symptoms. This limitation and their tendency to cause nosebleeds, insomnia and spikes in blood pressure means they are rarely recommended for general use.

Nasal sprays that contain nothing more than salt water are much safer. However, you do need to ensure you use uncontaminated sterile water to avoid introducing an invasive fungal infection into your nose. And as I have written previously, the benefits are inconclusive and inconsistent. People report less congestion, but time off work and the duration of the cold are unchanged by their use. 

The unfortunate reality is most of the over-the-counter products on the market have a very thin evidence base to back up their use. Painkillers like acetaminophen may make the ordeal of being sick slightly more tolerable, but most other products offer little benefit in exchange for their side-effect profile. Sadly, there is little regulatory zeal to get them off store shelves. As with most things, it is buyer beware. 

Christopher Labos is a Montreal physician. He’s the host of The Body of Evidence podcast and the author of Does Coffee Cause Cancer?

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