Allergic Rhinitis (Hay Fever)

Allergic rhinitis, commonly known as hay fever, affects millions of people worldwide, causing sneezing, congestion, and itchy eyes when the immune system overreacts to harmless particles in the air.

Table of contents

• What is allergic rhinitis?
• Other names
• What causes allergic rhinitis?
• Common triggers
• Types of allergic rhinitis
• How common is it?
• Symptoms
• How to tell it apart from a cold
• Diagnosis
• Treatment options
• Prevention and self-care
• When to see a doctor

What is allergic rhinitis?

Allergic rhinitis, also called hay fever, is an allergic reaction to tiny particles in the air called allergens (substances that trigger allergies). When you breathe in allergens through your nose or mouth, your body reacts by releasing a natural chemical called histamine (a substance your body produces during allergic reactions)^[1]. Despite being called hay fever, hay doesn’t cause this condition and most people don’t get a fever^[1].

Allergic rhinitis is not the same as infectious rhinitis, which is the common cold. Hay fever is not contagious^[1]. It is an IgE-mediated immune response (a type of allergic reaction involving specific antibodies) against inhaled particles that happens in two phases: an immediate phase and a late phase^[3].

Other names

hay fever, seasonal allergy, nasal allergy

What causes allergic rhinitis?

Allergic rhinitis occurs when your immune system mistakenly identifies a typically harmless substance as dangerous and overreacts to it^[2]. When a person with allergic rhinitis breathes in an allergen such as pollen, mold, animal dander, or dust, the body releases chemicals that cause allergy symptoms^[2].

The allergic response has two stages. In the early phase, which happens within 5 to 15 minutes of exposure, the body’s mast cells release histamine and other substances. Histamine causes sneezing and a runny nose. Other substances, such as leukotrienes (chemicals that cause inflammation) and prostaglandins (hormone-like substances), act on blood vessels to cause nasal congestion^[3].

Four to six hours after the initial response, a late-phase reaction develops. During this phase, various immune cells move into the nasal lining and produce swelling and continued congestion^[3].

Common triggers

Several indoor and outdoor allergens can cause hay fever. Common triggers include^[1]:

• Pollen from trees, weeds, grasses, and plants
• Mold spores
• Pet dander (tiny flakes of skin shed by animals)
• Dust mites (tiny insects that live in dust)
• Cockroach droppings and saliva

The types of plants that cause hay fever vary from person to person and from area to area^[2]. Tree, grass, and ragweed pollen is carried by the wind and can travel long distances. Flower pollen is carried by insects and does not usually cause hay fever^[2].

The amount of pollen in the air can affect whether symptoms develop. Hot, dry, windy days are more likely to have a lot of pollen in the air. On cool, damp, rainy days, most pollen is washed to the ground^[2].

Types of allergic rhinitis

There are two main types of allergic rhinitis based on when symptoms occur^[3]:

Seasonal allergic rhinitis occurs during specific times of the year. It happens in spring, summer, and early fall when trees and weeds bloom and pollen counts are higher. About 20% of cases are seasonal^[3]. Outdoor allergies are worse during warm weather when weeds and flowers bloom^[1].

Perennial allergic rhinitis causes year-round symptoms. It results from irritants that are always around, such as pet dander, cockroaches, and dust mites. About 40% of cases are perennial^[3]. Indoor allergies can get worse in winter because people spend more time indoors with their windows closed^[1].

About 40% of people have features of both seasonal and perennial allergic rhinitis^[3].

How common is it?

Hay fever is very common. In the United States, around 20% of the population has allergic rhinitis^[1]. It affects one in six individuals and is associated with significant effects on quality of life, lost productivity, and healthcare costs^[3]. In 2021, one study found that more than 81 million people had seasonal allergies^[1].

You are more likely to develop allergies if people in your family have them or conditions such as eczema and asthma. If both of your parents have hay fever or other allergies, you are likely to have them too. The chance is higher if your mother has allergies^[2].

Symptoms

Symptoms of hay fever can appear throughout the year, depending on what triggers them. They usually happen within minutes of coming into contact with something you’re allergic to^[5].

Common symptoms include^[1][2]:

• Nasal stuffiness (congestion), sneezing, and runny nose
• Itchy nose, throat, eyes, and mouth
• Red or watery eyes
• Headaches and sinus pressure
• Dark circles under the eyes (called allergic shiners)
• More mucus in your nose and throat
• Tiredness
• Sore throat from mucus dripping down your throat (postnasal drip: when mucus from the nose drips into the throat)
• Coughing

Symptoms that may develop later include stuffy nose, clogged ears and decreased sense of smell, puffiness under the eyes, and irritability^[2].

In addition to nasal symptoms, people with allergic rhinitis may also have eye allergy symptoms, a non-productive cough, problems with the tubes connecting the throat to the ears, and chronic sinus infections^[3].

How to tell it apart from a cold

Symptoms of a cold and hay fever are similar, but there are some differences. Itchy, red, and watery eyes are common with allergies but not as common with a cold. A cold is more likely to cause muscle aches, pain, or a fever^[1].

Another way to tell the difference is that allergic rhinitis usually has a trigger, like seasons changing or being around a new pet. Allergies often happen at the same time each year, like in spring and late summer, and they start quickly. On the other hand, a virus causes a cold, and you catch viruses from other people. You may know it’s a cold if you’ve been around someone with a cold. A cold tends to go away within a week^[1].

Diagnosis

Your healthcare provider will perform a physical exam and ask about your symptoms. You will be asked whether your symptoms vary by time of day or season and about your exposure to pets or other allergens^[2]. Knowing what symptoms you have, when you get them, and what makes them worse or better can help your doctor determine if you have allergies^[7].

Allergy testing may reveal the pollen or other substances that trigger your symptoms. Skin testing is the most common method of allergy testing. During a skin test, your skin is pricked and exposed to tiny bits of common allergens found in the air, such as dust mites, mold, pollen, and cat and dog dander. If you’re allergic to any of these, you’ll likely get a raised bump where your skin was pricked. If you’re not allergic, your skin won’t have changes^[2][4].

If your provider determines you cannot have skin testing, special blood tests may help with the diagnosis. These tests, known as IgE RAST tests, can measure the levels of allergy-related substances^[2].

Treatment options

Treatment for allergic rhinitis should be based on your age and the severity of your symptoms^[9]. The best treatment is to avoid the pollens and other allergens that cause your symptoms. However, it may be impossible to avoid all allergens, but you can often take steps to reduce your exposure^[2].

Medications

Intranasal corticosteroids (steroid nasal sprays) are the most effective treatment for allergic rhinitis. They work best when used continuously, but they can also be helpful when used for shorter periods. They should be first-line therapy for mild to moderate disease^[2][9].

Antihistamines are medicines that work well for treating allergy symptoms. They may be used when symptoms do not happen often or do not last long. Many antihistamines taken by mouth can be bought without a prescription. Some can cause sleepiness, so you should not drive or operate machines after taking this type. Others cause little or no sleepiness^[2]. Antihistamine nasal sprays work well for treating allergic rhinitis, and antihistamine eye drops can be used for itchy, watery eyes^[2].

Other treatment options include^[2][5]:

• Decongestants (medicines that reduce nasal stuffiness): Decongestant nasal sprays or drops can unblock your nose. However, they should not be used for more than a week as this can make symptoms worse^[5].
• Salt water nasal sprays or solutions to rinse out the inside of your nose
• Leukotriene receptor antagonists (medicines that block certain inflammatory chemicals)

Immunotherapy

Immunotherapy (allergy shots or tablets) should be considered in patients with a less than adequate response to usual treatments^[9]. During immunotherapy, you receive a regular dose of your allergen. Over time, your body gets used to the substance, your allergic reactions diminish, and your symptoms improve^[3].

Immunotherapy can be given as injections (allergy shots) or as tablets that dissolve under the tongue. Allergy shots are typically given every two weeks, beginning with a small dose and gradually increasing. Most people need 3 to 5 years of allergy shots to achieve the best results^[3].

Prevention and self-care

If you have allergic rhinitis, it’s not always possible to avoid the things you’re allergic to. But there are steps you can take to help reduce your symptoms^[5]:

• Keep windows closed during high pollen periods and use air conditioning in your home and car^[1]
• Wear wraparound sunglasses to protect your eyes from pollen^[5]
• Wear glasses or sunglasses when outdoors to keep pollen out of your eyes^[7]
• Limit outdoor activities when pollen counts are high^[7]
• Use hypoallergenic bedding and covers, and wash bedding regularly at 60°C and above^[5]
• Dust with a damp cloth and use a vacuum with a HEPA filter^[5]
• Wash pets at least once every two weeks and groom them outside regularly^[5]
• Regularly wash your pet’s bedding and clean any furniture they’ve been on^[5]
• Do not allow pets in bedrooms^[5]
• Keep your home dry and well-ventilated, and deal with any damp and condensation^[5]
• Use “mite-proof” bedding covers to limit exposure to dust mites and a dehumidifier to control mold^[7]
• Wash your hands after petting any animal^[7]

A nasal wash can help remove mucus from the nose. You can buy a saline solution at a drug store or make one at home using 1 cup of distilled or boiled then cooled water, half a teaspoon of salt, and a pinch of baking soda^[2].

Evidence does not support the use of mite-proof impermeable mattress and pillow covers, breastfeeding to prevent allergies, air filtration systems, or delayed exposure to solid foods in infancy^[9].

When to see a doctor

You should see a healthcare provider if^[5][7]:

• You have allergic rhinitis and your symptoms get worse
• You also have asthma and it’s getting worse
• Your symptoms are affecting your sleep and everyday life
• You’re not sure what’s causing your symptoms
• Treatments from a pharmacist are not working
• You have pain in the sinus area and other symptoms of sinus infection

If pharmacy medicines do not help ease your allergic rhinitis symptoms, a healthcare provider may prescribe a different medicine, such as prescription steroid nasal sprays or antihistamines. You may be referred to a specialist for further tests and treatment if it’s not clear what’s causing your symptoms or they’re severe^[5].