“Every spring my nose runs and I sneeze non-stop — antihistamines barely help any more”

Seasonal sneezing with bilateral nasal itch, watery rhinorrhoea, congestion and itchy watery eyes is classic ALLERGIC RHINITIS (hay fever), and the bilateral, symmetrical, seasonal pattern is itself reassuring. The commonest reason it "stops working" is UNDER-TREATMENT: a PRN oral antihistamine alone is insufficient for moderate-to-severe disease, where the mainstay is a REGULAR intranasal corticosteroid used DAILY through the season (BSACI 2017; starting a little before the season is common practice rather than a guideline figure), and most apparent failure reflects irregular use and poor SPRAY TECHNIQUE rather than a need for something exotic — so counsel technique explicitly (head slightly forward, opposite hand, aim away from the septum toward the outer wall, gentle sniff, days-to-2-weeks for effect). The full ladder: allergen avoidance; regular intranasal steroid + a non-sedating antihistamine; add intranasal antihistamine/combination spray, antihistamine eye drops and saline; consider a leukotriene antagonist selectively (especially with asthma), counselling on the montelukast neuropsychiatric warnings (MHRA Drug Safety Update September 2019; April 2024), and a SHORT oral steroid course only for severe acute flares (never depot injections); and ENT/allergy referral for immunotherapy in severe, refractory, single-allergen cases — while avoiding prolonged decongestant sprays (rhinitis medicamentosa). Crucially, voice the rhinitis RED FLAGS that are NOT simple hay fever and warrant ENT referral: persistent UNILATERAL nasal obstruction, unilateral blood-stained/bloody discharge, a unilateral mass/polyp, facial pain/swelling/numbness, or orbital symptoms — which can indicate a sinonasal tumour (BSACI 2017). ENT referral for unilateral or bloody features is made on clinical grounds, with urgency set by the features, and this red-flag teaching must be made explicit as safety-netting.