Recurrent Nosebleeds: Causes, First Aid and When to Get Tested

Nosebleeds are divided anatomically into anterior and posterior. Anterior bleeds, far more common, come from the front of the nasal septum, where branches of several arteries form a dense vascular network (Kiesselbach's area). The vessels lie shallowly there, and the mucous membrane is thin and exposed to dry air, so it breaks easily. Such bleeding is usually visible from one nostril and can generally be controlled with pressure.

Posterior bleeds are rarer, come from deeper vessels at the back of the nasal cavity, and are more common in older people and in those with vascular disease or clotting disorders. Blood then runs down the throat, often on both sides, and can be hard to control with self-applied pressure. They need assessment in hospital: the guideline provides for packing and, if that fails, procedures such as arterial ligation or embolisation.

Two conclusions matter in practice. First, it is worth identifying the bleeding site, because treatment depends on it: the guideline advises examining the nose (anterior rhinoscopy) after clots are removed, and performing nasal endoscopy for bleeding that recurs despite earlier treatment or recurs only on one side. Second, bleeding that keeps returning from the same nostril is more suspicious than bilateral bleeding caused by dryness, and needs ENT assessment.

In practice, several factors often combine: dry air in winter, a mild rhinitis, a habit of picking or blowing hard, and on top of that a drug that affects clotting. A careful history (when, which side, how long, after what, which drugs) is therefore often worth more than a large panel of tests.

The guideline advises clinicians to document factors that increase the frequency and severity of bleeding: a personal or family history of bleeding disorders, use of anticoagulant or antiplatelet drugs, and use of nasal drugs. This is also a good list for the patient: gather this information before the visit, including over-the-counter products and supplements.

This is one of the most common questions and one of the more contested. Intuitively, high pressure might contribute to bleeding, and a nosebleed is often accompanied by a high reading at the surgery or in the emergency department. Studies show, however, that an association exists but it is not known whether it is causal.

What does this mean in practice? People with hypertension experience nosebleeds more often, but observational studies alone do not settle whether blood pressure is the cause or whether accompanying factors (age, drugs, vascular changes, the stress of the bleeding episode itself raising pressure) are. There is also no evidence that a person with a nosebleed and normal pressure needs to be searched for hidden hypertension. It is reasonable, however, for someone with recurrent bleeds to have their pressure measured outside an episode, and well controlled if hypertension has been diagnosed.

Drugs that inhibit clotting or platelet function do not usually cause nosebleeds by themselves, but they make a small vessel injury harder to stop, so bleeding is longer or more frequent. The AAO-HNS guideline explicitly singles out patients taking such drugs as a special group in which the choice of packing and the approach to management differ.

The guideline advises that, in people using anticoagulant or antiplatelet drugs and in the absence of life-threatening bleeding, first-line treatment (pressure, packing, cautery) should be used first, and only then should transfusion, reversal or withdrawal of the drugs be considered. Resorbable packing is also recommended in these patients. This matters for the patient: do not stop anticoagulant treatment yourself because of nosebleeds, because the risk of thrombosis or stroke may be greater than the risk of the nosebleed. A decision to change the dose belongs to the doctor who prescribed the drug.

If you take warfarin, bleeding may point to an INR that is too high; we write about interpreting clotting tests in the entry on INR, APTT and PT. Frequent use of non-steroidal anti-inflammatory drugs and aspirin, including over the counter, also increases the tendency to bleed, so it is worth including in the history before looking for rarer causes.

Rarely but importantly, recurrent nosebleeds are the first sign of a systemic disease. The most common inherited bleeding disorder is von Willebrand disease, and nosebleeds are among its typical features alongside heavy periods, easy bruising and prolonged bleeding after procedures. Family history (nosebleeds, heavy periods or bleeding after procedures in relatives) is one of the most valuable parts of the assessment.

The second diagnosis worth remembering is hereditary haemorrhagic telangiectasia (HHT), an autosomal dominant disease with an estimated prevalence of 1 in 5000, characterised by vascular malformations. The AAO-HNS guideline advises looking for telangiectasias on the lining of the nose and mouth in people with recurrent bilateral nosebleeds or a family history of recurrent bleeding. The malformations can cause chronic bleeding and iron-deficiency anaemia, and the international HHT guidelines separately address the management of nosebleeds, anaemia and iron deficiency.

The mainstay of treating a bleed from the front of the nose is pressure. The AAO-HNS guideline advises firm, sustained pressure on the lower, soft part of the nose for at least 5 minutes, applied by the person themselves or with the help of a carer. The key point is that the pressure must be continuous: repeatedly checking whether the bleeding has stopped breaks up the forming clot and prolongs the bleed.

The details of position (leaning forward, breathing through the mouth) come from clinical practice and the logic of keeping blood out of the throat; in the literature we searched we did not find randomised trials comparing body positions. Best documented is the pressing of the lower nose for a sufficient time, as stated in the guideline.

The guideline lists three main ways to treat an identified bleeding site: topical vasoconstrictors, cautery and moisturising or lubricating agents. For a person with recurrences, what matters in practice is that moisturising the mucosa (for example with saline, gels or nasal ointments recommended by a doctor or pharmacist) is part of prevention, not only treatment after the fact. The guideline does not name a single preparation as best, so the choice is worth discussing with a doctor.

When cautery is the chosen treatment, the guideline advises anaesthetising the bleeding site and restricting cautery to the active or suspected site, which reduces the risk of damaging the septum. For bleeding not controlled by packing or cautery, arterial ligation or embolisation is considered, but these are hospital situations.

What about tranexamic acid? A 2018 Cochrane review included 6 trials with 692 adults. Added to standard care, tranexamic acid (oral or topical) probably reduced the risk of re-bleeding: from 67% to 47% (RR 0.71; 95% CI 0.56-0.90; three trials, 225 participants; moderate-quality evidence). For topical use alone, evidence from a single trial was of low quality, so it is uncertain whether a single application stops bleeding within 10 days. The authors point out that only three trials have been done since 1995 and treatment techniques have changed considerably. This is a drug used at a doctor's choice, not something to use on your own.

Most nosebleeds can be controlled at home. The following situations, however, need medical assessment, and some need urgent help. The threshold of 20-30 minutes of pressure is a rule of thumb used in practice, not a figure from the studies cited.

A nosebleed looks alarming, but in most cases it is a minor problem with a specific, often removable cause: dry air, irritation, a drug. Collected information helps: which side, how often, after what, on which drugs. When bleeds keep coming back despite simple measures, or come with other symptoms, it is worth moving on to ENT assessment and possibly blood tests, instead of managing for years with pressure alone.