Which Allergy Medications Are Prescription Only? Hydroxyzine, Montelukast, and More

Seasonal allergies affect millions of people in the U.S. every year. Most people can find relief with over-the-counter (OTC) medications. But not all allergy treatments are available OTC. So, which allergy medications are prescription only? And are they any better than OTC options?

Prescription-only antihistamines

Antihistamines work by blocking the chemical histamine in your body. Histamine causes many allergy symptoms, such as sneezing and itchy, watery eyes. Many antihistamines are available OTC. But several require a prescription.

Below are notable prescription-only antihistamines. This isn’t a complete list.

Hydroxyzine

Hydroxyzine is the most commonly prescribed antihistamine. There are two forms of this medication: hydroxyzine hydrochloride and hydroxyzine pamoate (Vistaril). The two forms work similarly and are FDA approved for the same uses.

Hydroxyzine is approved for:

• Itching caused by allergic skin conditions, such as hives

• Anxiety

• Sedation while receiving general anesthesia during surgery

Promethazine

Promethazine is a prescription-only antihistamine that can be used for allergies. But it’s more commonly prescribed for nausea. In fact, there is a rectal suppository version of the medication (Promethegan). This dosage form can be helpful for managing nausea or vomiting that’s preventing you from swallowing pills.

Promethazine has several FDA-approved uses:

• Allergy symptoms

• Runny or stuffy nose that isn’t caused by allergies (vasomotor rhinitis)

• Symptoms of more serious allergic reactions, such as rash or swelling

• Dermographia (“skin writing”)

• Treatment or prevention of nausea and vomiting

• Treatment or prevention of motion sickness

• Pain relief following surgery (when combined with other pain medications)

• Sedation to prepare for certain surgical procedures

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Azelastine (certain doses and forms)

Azelastine comes as an eye drop and a nasal spray. The eye drop and the 0.1% dose of the nasal spray require a prescription. A different-dose (0.15%) nasal spray is available OTC (Astepro).

Azelastine eye drops are approved to relieve itchy eyes that are caused by allergies. Prescription-only azelastine nasal spray is approved to treat:

• Seasonal allergy symptoms that affect the nose

• Vasomotor rhinitis

Zerviate

Zerviate (cetirizine) is a prescription-only antihistamine eye drop. It’s similar to azelastine eye drops. And it’s approved to treat itchy eyes related to allergies.

Good to know: Cetirizine, Zerviate’s active ingredient, is available OTC as the oral medication Zyrtec.

Epinastine

Epinastine (Elestat) is another antihistamine eye drop. It’s similar to Zerviate and azelastine eye drops. But while Zerviate and azelastine can help treat itchy eyes due to allergies, epinastine can help prevent it.

Patanase

Patanase (olopatadine) is a prescription-only antihistamine nasal spray. It’s approved to treat allergy symptoms that affect both the eyes and nose.

Patanase is similar to azelastine nasal spray. But fewer people experience a bitter taste after using Patanase. So you may find that it’s easier to tolerate.

Clarinex

Clarinex (desloratadine) is an antihistamine that’s chemically similar to Claritin (loratadine). But Claritin is available OTC, while Clarinex is prescription only. Clarinex has a low risk of side effects compared with the other prescription oral antihistamines on this list.

Clarinex is approved for:

• Seasonal allergies

• Year-round allergies

• Chronic hives (only some generic versions are approved for this)

Cyproheptadine

Cyproheptadine is an antihistamine that’s been around since the 1960s. It can treat several allergy-related symptoms. But it’s sometimes used off-label to stimulate appetite.

Cyprohepatidine’s approved uses include treating:

• Year-round and seasonal allergies

• Vasomotor rhinitis

• Eye allergies

• Mild skin allergies

• Allergic reactions to blood or plasma

• Hives after exposure to cold temperatures

• Dermographia

• Severe allergic reactions, including anaphylaxis (when combined with other treatments)

Prescription-only nasal steroids

Nasal corticosteroids (“steroids”) are a first-choice option for managing severe or persistent allergy symptoms. Many nasal steroids are available OTC. But some require a prescription.

Flunisolide

Flunisolide is a prescription-only nasal steroid. It’s FDA approved to manage nasal symptoms caused by seasonal or year-round allergies. It’s not recommended to use flunisolide if you have symptoms due to an infection.

Qnasl

Qnasl (beclomethasone) is another option with prescription-only nasal steroids. Like flunisolide, Qnasl is approved to manage nasal symptoms related to seasonal or year-round allergies.

In the past, Qnasl’s active ingredient was also sold under a second brand name, Beconase AQ. This brand-name nasal steroid was discontinued in 2023. But you may have been on Beconase AQ in the past and then switched to Qnasl after the discontinuation.

Ciclesonide

Ciclesonide (Omnaris, Zetonna) is another nasal steroid. It’s approved for the same uses as the nasal sprays listed above. But there are differences between each brand name for ciclesonide. The table below highlights notable distinctions.

Xhance

Xhance (fluticasone propionate) contains the same steroid as OTC Flonase (fluticasone propionate). But Xhance has different dosages and uses that Flonase doesn’t. The table below compares some of the differences between the two.

Singulair

Singulair (montelukast) is a leukotriene receptor antagonist. It’s the only medication in its class that’s approved to manage seasonal and year-round allergies. But it’s not a first choice.

Singulair doesn’t work as well as other allergy medications. And it has a risk of serious behavioral and mood-related side effects. Because of this, experts recommend trying other allergy medications before taking Singulair.

Singulair is also approved to manage chronic and exercise-induced asthma. So it may be an option if you have both allergies and asthma (allergic asthma).

Prescription-only combination allergy medications

Combination allergy medications include multiple medications that help manage allergies. This can help simplify your allergy treatment regimen. And depending on your insurance plan, combination medications could also help reduce costs.

Examples of prescription-only combination allergy medications can be found in the table below.

Allergy immunotherapy

Allergy immunotherapy trains your immune system not to overreact when you’re exposed to allergens. You’ll start by receiving a small amount of a substance that you’re allergic to. Over several months, this dose will go up. The goal is for your body to build up a tolerance to an allergen.

Allergy shots are a common form of immunotherapy. Other examples include:

• Odactra, used for house dust mite allergies

• Grastek, used for timothy grass pollen allergies

• Palforzia, used for peanut allergies

• Ragwitek, used for ragweed allergies

• Oralair, used for mixed grass pollen allergies

Do prescription allergy medications work better than OTC allergy medications?

Not usually. Experts don’t recommend certain medications over others within a class. There may be slight differences in how a medication works compared with others in its class. But all of them would be considered effective options.

For instance, studies suggest that OTC Nasonex (mometasone) was slightly more effective than other nasal steroids for seasonal allergies. But all nasal steroids provided significant allergy relief compared with no treatment at all.

A notable exception to this is seen with antihistamine / nasal steroid combinations. Research has found that Dymista is more effective than using azelastine or fluticasone (Dymista’s active ingredients) alone. The same was found for Ryaltris. Clinical trials have shown that the combination product is more effective than the individual medications by themselves.

Keep in mind that you can buy the individual medications included in Dymista OTC. You could buy OTC Astepro and Flonase and use both. So it’s possible to achieve this added effectiveness with OTC allergy medications. But it may be more convenient and cost-effective to use a combination nasal spray versus two separate products. And the combination nasal sprays are prescription only.

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Written by:

Christina Aungst, PharmD

Christina Aungst, PharmD, is a pharmacy editor for GoodRx. She began writing for GoodRx Health in 2019, transitioning from freelance writer to editor in 2021.

Reviewed by:

Tegan Smedley, PharmD, APh

Tegan Smedley, PharmD, APh, has 10 years of experience as a pharmacist. She has worked in a variety of settings, including retail, hospital, and ambulatory care.

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