If you need fast, reliable relief from seasonal or perennial allergies, not all medicines perform the same. This ranked list compares the most common options by how well they work overall, how quickly they kick in, and how tolerable their side effects are—so you can pick the right tool for your symptoms.
How we ranked
- Effectiveness: How strongly the medicine improves core nasal/eye symptoms in studies and guidelines.
- Speed: How quickly most people notice relief.
- Side effects: Likelihood and impact of common issues like drowsiness or rebound congestion.
- Evidence base: Strength and consistency of data in respected guidelines, labels, and peer‑reviewed studies.
- Azelastine + fluticasone nasal spray (combo; e.g., Dymista)
- Why it ranks #1: Consistently superior nasal symptom control vs either ingredient alone.
- Effectiveness: High; improves total nasal symptom scores more than intranasal steroid or antihistamine monotherapy in RCTs.
- Speed of relief: Often within the first dose; improvements seen as early as 30 minutes in trials.
- Side effects: Bitter taste, nasal irritation/bleeds; occasional mild drowsiness from azelastine.
- Best for: Moderate–severe allergic rhinitis, especially when monotherapy isn’t enough.
- OTC/Rx: Prescription.
- Key sources: RCT showing superiority vs either agent alone (Carr et al., JACI) https://pubmed.ncbi.nlm.nih.gov/22414759/; Product label (DYMISTA) https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1ad1ecaf-4c55-4ec6-8c13-69b3a7be3c7f; Guideline summary (AAFP) https://www.aafp.org/pubs/afp/issues/2015/1201/p985.html
- Intranasal corticosteroids (INCS; fluticasone, budesonide, triamcinolone, mometasone)
- Why it ranks #2: Most effective single‑agent therapy for nasal symptoms; excellent for congestion.
- Effectiveness: High across sneezing, itching, runny nose, and especially congestion; guideline first‑line.
- Speed of relief: Starts in 12–24 hours; best effect after several days of daily use.
- Side effects: Local dryness/irritation, nosebleeds; minimal systemic effects at usual doses.
- Best for: Daily control of persistent or moderate–severe nasal symptoms.
- OTC/Rx: Mostly OTC (check specific product).
- Key sources: Guideline summary—INCS are first‑line and most effective monotherapy https://www.aafp.org/pubs/afp/issues/2015/1201/p985.html; Mayo Clinic overview (onset) https://www.mayoclinic.org/diseases-conditions/allergies/in-depth/allergy-medications/art-20047403
- Intranasal antihistamines (azelastine [now OTC], olopatadine)
- Why it ranks #3: Rapid relief and better for congestion than oral antihistamines; useful as add‑on to INCS.
- Effectiveness: Moderate–high; can help congestion and postnasal drip more than oral antihistamines.
- Speed of relief: Rapid (about 15 minutes).
- Side effects: Bitter taste, nasal irritation; mild drowsiness possible.
- Best for: Quick symptom relief, episodic use, or add‑on to INCS.
- OTC/Rx: Azelastine nasal is OTC in the U.S.; olopatadine nasal is Rx.
- Key sources: Intranasal antihistamines—rapid onset and congestion benefit https://www.aafp.org/pubs/afp/issues/2015/1201/p985.html; FDA OTC switch for azelastine nasal (Astepro) https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-nasal-antihistamine
- Cetirizine (oral; e.g., Zyrtec)
- Why it ranks #4: Strong symptom control among oral antihistamines; once‑daily.
- Effectiveness: Good for sneezing, itching, rhinorrhea; modest for congestion.
- Speed of relief: About 1 hour.
- Side effects: Drowsiness in some (more than fexofenadine or loratadine); dry mouth.
- Best for: Daily control when nasal sprays aren’t preferred; intermittent use.
- OTC/Rx: OTC.
- Key sources: MedlinePlus monograph (uses, drowsiness) https://medlineplus.gov/druginfo/meds/a698026.html; Mayo Clinic overview https://www.mayoclinic.org/diseases-conditions/allergies/in-depth/allergy-medications/art-20047403
- Fexofenadine (oral; e.g., Allegra)
- Why it ranks #5: Among the least sedating options; good daytime choice.
- Effectiveness: Good for sneezing/itching; modest for congestion.
- Speed of relief: About 1 hour.
- Side effects: Minimal drowsiness; avoid taking with fruit juices (reduces absorption).
- Best for: People sensitive to drowsiness (driving, work, school).
- OTC/Rx: OTC.
- Key sources: MedlinePlus (fruit juice interaction, profile) https://medlineplus.gov/druginfo/meds/a697035.html; Mayo Clinic overview https://www.mayoclinic.org/diseases-conditions/allergies/in-depth/allergy-medications/art-20047403
- Loratadine (oral; e.g., Claritin)
- Why it ranks #6: Well‑tolerated, once‑daily, widely available.
- Effectiveness: Moderate for sneezing/itching; modest for congestion.
- Speed of relief: Around 1 hour for many users.
- Side effects: Low drowsiness risk; dry mouth, headache possible.
- Best for: Mild–moderate symptoms or when sedation must be minimized.
- OTC/Rx: OTC.
- Key sources: MedlinePlus monograph https://medlineplus.gov/druginfo/meds/a697038.html; AAFP comparative guidance https://www.aafp.org/pubs/afp/issues/2015/1201/p985.html
- Ketotifen ophthalmic drops (e.g., Zaditor, Alaway)
- Why it ranks #7: Go‑to for itchy, watery eyes; dual action (antihistamine + mast‑cell stabilizer).
- Effectiveness: High for ocular itch and redness; 8–12 hours of relief per dose.
- Speed of relief: Fast acting for eye symptoms.
- Side effects: Temporary stinging, dry eyes; rarely headache.
- Best for: Predominantly eye symptoms or add‑on to nasal therapy.
- OTC/Rx: OTC.
- Key sources: MedlinePlus (ketotifen ophthalmic) https://medlineplus.gov/druginfo/meds/a604025.html
- Cromolyn sodium nasal spray (e.g., NasalCrom)
- Why it ranks #8: Extremely safe; best used preventively.
- Effectiveness: Modest; benefits increase with continuous use.
- Speed of relief: Slow—may take several days to weeks for full effect.
- Side effects: Very well tolerated; occasional nasal irritation/sneezing.
- Best for: Preventive use (start before pollen season), pregnancy, or those who prefer ultra‑low risk options.
- OTC/Rx: OTC.
- Key sources: MedlinePlus (onset and use) https://medlineplus.gov/druginfo/meds/a682575.html; AAFP overview https://www.aafp.org/pubs/afp/issues/2015/1201/p985.html
- Pseudoephedrine (oral decongestant)
- Why it ranks #9: Reliably opens stuffy noses; best as a short‑term add‑on.
- Effectiveness: Good for nasal congestion; not for itch/sneeze.
- Speed of relief: Generally fast.
- Side effects: Jitteriness, insomnia, increased heart rate/blood pressure; avoid late in the day and in uncontrolled hypertension.
- Best for: Short bursts of severe congestion or as-needed add‑on to antihistamine/INCS.
- OTC/Rx: Available without prescription but kept “behind the counter” in pharmacies in the U.S.
- Key sources: MedlinePlus (warnings) https://medlineplus.gov/druginfo/meds/a682619.html; FDA notes that oral phenylephrine (common alternative) lacks evidence of effectiveness https://www.fda.gov/drugs/drug-safety-and-availability/fda-clarifies-results-recent-advisory-committee-meeting-oral-phenylephrine
- Oxymetazoline nasal spray (e.g., Afrin)
- Why it ranks #10: Fastest congestion relief—but only for very short use.
- Effectiveness: Very high decongestant effect within minutes.
- Speed of relief: Very fast.
- Side effects: Risk of rebound congestion if used >3 days; local dryness/irritation; caution in hypertension/glaucoma.
- Best for: Severe, short-term nasal blockage (e.g., before sleep or travel), ideally paired with an INCS for ongoing control.
- OTC/Rx: OTC.
- Key sources: MedlinePlus (do not use >3 days) https://medlineplus.gov/druginfo/meds/a682661.html; Mayo Clinic overview https://www.mayoclinic.org/diseases-conditions/allergies/in-depth/allergy-medications/art-20047403
Honorable mentions and important cautions
- Montelukast (oral leukotriene receptor antagonist): Not ranked for routine allergic rhinitis due to FDA boxed warning for serious neuropsychiatric events; generally reserved when other options fail. Source: FDA safety communication https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-stronger-warning-about-risk-neuropsychiatric-events-associated-allergy-asthma-medicine
- Oral phenylephrine: The FDA advisory committee concluded available data do not support efficacy as a nasal decongestant; choose pseudoephedrine when appropriate. Source: FDA statement https://www.fda.gov/drugs/drug-safety-and-availability/fda-clarifies-results-recent-advisory-committee-meeting-oral-phenylephrine
Quick picks by need
- Best overall nasal control: Azelastine + fluticasone combo (Rx), or INCS alone if you prefer OTC.
- Fastest congestion relief: Oxymetazoline nasal (max 3 days) or pseudoephedrine oral.
- Least sedating daytime antihistamine: Fexofenadine.
- Eyes driving you crazy: Ketotifen ophthalmic drops.
- Safest preventive option: Cromolyn nasal (start before your season).
Final tips for safer, better relief
- Use nasal sprays correctly to improve results and reduce nosebleeds (aim slightly outward, not toward the septum).
- For daily symptoms, stick with once‑daily INCS; add an intranasal antihistamine or oral antihistamine if needed.
- Check interactions and cautions if you have high blood pressure, glaucoma, prostate issues, or are pregnant/breastfeeding; ask your clinician or pharmacist.
- If medicines aren’t enough or you want to reduce long‑term medication use, ask about allergen immunotherapy (shots or tablets).