see also: Chronic Cough Evaluation and Differential Diagnosis

updated 11-06-2023 by Edward Tannenbaum BS and H Hoffman MD

Four common causes of cough are asthma, upper airway cough syndrome, GERD, and ACE inhibitors. The management options for neurogenic cough, which is usually a diagnosis of exclusion, will also be discussed here. There are also some investigational medications underway. Literature review permits citing a broad review of both non-pharmacological and pharmacological treatment options for the common causes of cough. See Chronic Cough Evaluation and Differential Diagnosis for diagnosing chronic cough. 

A. Asthma (cough-variant)

• Lifestyle modifications: avoid triggers
• One approach supports use of short-acting beta agonists at onset of asthma symptoms; if refractory, the following medications could be considered to be trialed in a stepwise fashion until asthma is controlled: inhaled corticosteroids -> long-acting beta agonists -> leukotriene receptor antagonists -> biologic therapies -> oral steroids (Côté A 2020, Cheriyan 1994)

B. Upper airway cough syndrome

• Treat the cause of upper airway cough syndrome: 
  • Allergic rhinitis - intranasal steroids (Flonase, Nasacort, or Rhinocort); may take up to 2 weeks for maximal effect (Morice et al., 2006; Gawchik et al., 2003; McGarvey et al., 1998)
  • Non-allergic rhinitis - intranasal glucocorticoids or intranasal ipratropium; may also try intranasal azelastine (can have a sedatory effect) (Macedo et al., 2009)
  • Unknown origin - first-generation antihistamine-decongestant therapy (diphenhydramine, chlorpheniramine, hydroxyzine) +/- intranasal corticosteroids (Morice et al., 2006; Gawchik et al., 2003)
• Nasal saline irrigations help eliminate debris, allergens, and inflammatory markers, and therefore may be useful in allergic rhinitis. This approach may mechanically reduce postnasal drainage, and therefore, cough (Carroll, 2019).

C. Gastroesophageal reflux disease

• Lifestyle modifications  (see: Esophageal Reflux Precautions)
  • Avoid fatty foods, chocolate, alcohol, caffeinated beverages, carbonated beverages, red wine, orange juice, and mint
  • Have dinner at least 2-3 hours before bedtime (i.e., avoid laying down immediately after meals)
  • Sleep with the head elevated to avoid reflux
  • Smoking cessation
  • If overweight, weight loss can play a role in reducing heartburn. "[I]ncreased abdominal fat increases basal intra-abdominal perssure and risk of...reflux events" (Carroll, 2019).
  • Consider alkaline water (Zalvan 2017) - other low acid diet modifications including low acid coffee (if abstinence from coffee not an option)
• Acid suppression with medications
  • PPI taken 30 minutes before eating for 2-3 months, then taper to off (Kahrilas et al., 2013) (duration of treatment is debatable).
  • Antacids as needed for heartburn; do not take more than directed
• Aspirin, nitrates, and calcium channel blockers increase esophageal reflux; having these medications on an empty stomach can especially increase reflux (Carroll, 2019).
• Procedures/surgeries for reflux-related cough: Nissen fundoplication (Hoppo et al., 2013; Caroll et al., 2016), Linx Reflux Management System (Kethman & Hawn, 2017), laparoscopic Roux-en-Y gastric bypass (for obese patients)

D. ACE Inhibitors (Lisinopril, Enalapril, Benazepril, etc.)

• Cough usually presents within 1-2 weeks of starting an ACE inhibitor but can take up to 6 months (Dicpinigaitis, 2006). 
• Cough will resolve anywhere from 1 week to 3 months after withdrawal from the ACE inhibitor. PCP can prescribe an ARB (angiotensin II receptor blocker) in place of the ACE inhibitor. 

E. Neurogenic cough ​

• Gabapentin/pregabalin - GABA analogs that inhibit voltage-gated calcium channel neurotransmitter release (Altman et al., 2015)
• Amitriptyline - has strong anticholinergic effects compared to other TCAs; caution in patients older than 65 years (Carroll, 2019)
• Other agents: Tramadol and baclofen - second-line therapies (Altman et al., 2015)
• Cough retraining (speech) therapy (Vertigan et al., 2006) - The goal is to decrease sensitivity to the cough-reflex by establishing better control over a voluntary cough (Hutchings et al., 1993)
  • Vocal hygiene: smoking cessation, nasal breathing (reduces dryness and irritation to the larynx), staying hydrated, breathing humidified air (Carroll, 2019)
  • Behavioral (Carroll, 2019; Steinhauer et al., 2017; Mathers-Schmidt, 2001)
    • Exchange cough with swallowing (dry or with water), swallowing while actively lowering the larynx, sucking on ice, or sucking on a sugar-free nonmedicated lozenge.
    • Sniff (abducts the vocal folds).
    • Pursed-lip breathing
    • Inhaling through a straw
    • Open throat posture through "silent laughing" 
    • Relaxed throat breathing 
    • Postural alignment 
  • Respiratory retraining
  • Voice therapy
• On-line Resource from Dr. Bastian addressing sensori-neuropathic cough: https://laryngopedia.com/sensory-neuropathic-cough/
• History
  • Key feature: coughing fit usually, but not always, preceded by abrupt sensation in throat, often described as a “tickle,” “sudden dry patch,” or “dripping mucus” (Bastian, n.d.).
  • Inclusion criteria (Bastian et al., 2006):
    • Intractable, idiopathic, chronic cough
    • Some severe episodes that last 10 seconds to 2 minutes, frequently with rhinorrhea and vomiting, sometimes with laryngospasm, syncope, or presyncope
    • Cough may occur spontaneously or may be triggered by talking, laughing loudly, breathing cold air, moving to a supine position, swallowing (without aspiration), light touch, yawning, singing.
    • Nonproductive cough but if productive, always at end of severe episode (i.e., not the cause of coughing)
  • Exclusion criteria (Bastian et al., 2006):
    • Emotional disconnection from issue
    • Identifiable secondary gain
    • Sudden onset/offset
  • PMH: Comorbid MTD, throat clearing, prior lack of improvement with 3 months PPI and inhaled steroids
  • Postviral vagal neuropathy chronic cough history (Gibson et al., 2011)
    • Dysphagia, effortful phonation, breathy dysphonia, globus, vocal fatigue
• Physical Exam
  • Sensitivity at the superior laryngeal nerve entry sites on neck exam

F. Other methods

• Botox - injections into the thyroarytenoid muscle (Sipp et al., 2007)
• Superior laryngeal nerve block - long-acting particulate steroid + a local anesthetic injected at the entry point of the internal branch of the superior laryngeal nerve block (Simpson et al., 2018)

G. Investigational Medications:

• Gefapixant - P2X3 antagonist. A randomized, two double-blind, placebo-controlled trial showed a decrease in frequency of cough in 24 hours over a 12-week study. Taste disturbance was the most common adverse effect. Not FDA-approved (Abdulqawi, et al., 2015).
• Nebulized lidocaine - A study shows frequency of cough decreased over two weeks but there were many significant adverse effects: unpleasant taste, throat irritation, and choking (Lim et al., 2013). 

References

Gray AJ, Hoffman MR, Yang ZM, Vandiver B, Purvis J, Morgan JP, Hapner ER, Dominguez L, Tibbetts K, Simpson CB. Indications and Short-Term Outcomes for In-Office Therapeutic Superior Laryngeal Nerve Block. Ann Otol Rhinol Laryngol. 2023 Aug 22:34894231194384. doi: 10.1177/00034894231194384. Epub ahead of print. PMID: 37608685.

Shaha M, Hoffman MR, Hapner ER, Simpson CB. Membranous Vocal Fold Lesions in Patients With Chronic Cough: A Case Series. J Voice. 2023 Mar 11:S0892-1997(23)00040-1. doi: 10.1016/j.jvoice.2023.02.006. Epub ahead of print. PMID: 36907683.

Carroll, T.L. (Ed.). (2019). Chronic cough. LOGO Plural Publishing. Retrieved July 16, 2022, from https://ebookcentral-proquest-com.dmu.idm.oclc.org/lib/dmu-ebooks/reader....

Morice AH, McGarvey L, Pavord I. Recommendations for the management of cough in adults. Thorax. 2006;61(suppl 1):1-25. 

Gawchik S, Goldstein S, Prenner B, John A. Relief of cough and nasal symptoms associated with allergic rhinitis by mometasone furoate nasal spray. Ann Allergy, Asthma Immunol. 2003;90(4): 416-421.

McGarvey L, Heaney L, Lawson J, et al. Evaluation and outcome of patients with chronic non-productive cough using a comprehensive diagnostic protocol. Thorax. 1998;53:738-743.

Macedo P, Saleh H, Torrego A, et al. Postnasal drip and chronic cough: an open interventional study. Respir Med. 2009;103(11):1700-1705.

Kethman W, Hawn M. New approaches to gastroesophageal reflux disease. J Gastrointest Surg. 2017;21(9):1544-1552. doi:10.1007/s11605-017-3439-5

Kahrilas PJ, Howden CW, Hughes N, Molloy-Bland M. Response of chronic cough to acid-suppressive therapy in patients with gastroesophageal reflux disease. Chest. 2013;143(3):605-612. doi:10.1378/chest.12-1788

Hoppo T, Komatsu Y, Jobe BA. Antireflux surgery in patients with chronic cough and abnormal proximal exposure as measured by hypopharyngeal multi-channel intraluminal impedance. JAMA Surg. 2013;148(7):608. doi:10.1001/jamasurg.2013.1376

Caroll TL, Nahikian K, Asban A, Wiener D. Nissen fundoplication for laryngopharyngeal reflux after patient selection using dual pH, full column impedance testing. Ann Otol Rhinol Laryngol. 2016;125(9):722-728. doi:10.1177/0003489416649974

Altman KW, Noordzij JP, Rosen CA, Cohen S, Sulica L. Neurogenic cough. Laryngoscope. 2015;125(7):1675-1681.

Vertigan AE, Theodoros DG, Gibson PG, Winkworth AL. Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy. Thorax. 2006; 61(12):1065-1069.

. Hutchings HA, Eccles R, Smith AP, Jawad MS. Voluntary cough suppression as an indication of symptom severity in upper respiratory tract infections. Eur Respir J. 1993;6(10):1449-1454.

Steinhauer K, McDonald Klimek M, Estill J. The Estill Voice Model: Theory Translation. Pittsburgh, PA: Estill Voice International; 2017.

Mathers-Schmidt BA. Paradoxical vocal fold motion: a tutorial on a complex disorder and the speech-language pathologist's role. Am J Speech Lang Pathol. 2001;10:111-125.

Sipp JA, Haver KE, Masek BJ, Hartnick CJ. Botulinum toxin A: a novel adjunct treatment for debilitation habit cough in children. Ear Nose Throat J. 2007;86(9):570-572.

Simpson CB, Tibbetts KM, Loochtan MJ, Dominguez LM. Treatment of chronic neurogenic cough with in-office superior laryngeal nerve block. Laryngoscope. 2018;128(8):1898-1903.

Abdulqawi R, Dockry R, Holt K, et al. P2X3 receptor antagonist (AF-219) in refractory chronic cough: a randomised, double-blind, placebo-controlled phase 2 study. Lancet 2015; 385:1198.

Lim KG, Rank MA, Hahn PY, et al. Long-term safety of nebulized lidocaine for adults with difficult-to-control chronic cough: a case series. Chest 2013; 143:1060.

Dicpinigaitis PV. Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:169S.

Cheriyan S, Greenberger PA, Patterson R. Outcome of cough variant asthma treated with inhaled steroids. Ann Allergy. 1994;73(6):478. 

Côté A, Russell RJ, Boulet LP, Gibson PG, Lai K, Irwin RS, Brightling CE, CHEST Expert Cough Panel. Managing Chronic Cough Due to Asthma and NAEB in Adults and Adolescents: CHEST Guideline and Expert Panel Report. Chest. 2020;158(1):68. Epub 2020 Jan 20.

Zalvan CH, Hu S, Greenberg B, and Geliebter J: A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux  JAMA Otolaryngol Head Neck Surg. 2017;143(10):1023-1029

Gibson PG, Ryan NM. Cough pharmacotherapy: current and future status. Expert Opin Pharmacother. 2011;12(11):1745-1755. doi:10.1517/14656566.2011.576249

Bastian, R. (n.d.). Sensory neuropathic cough. Laryngopedia. https://laryngopedia.com/sensory-neuropathic-cough/

Bastian RW, Vaidya AM, Delsupehe KG. Sensory neuropathic cough: a common and treatable cause of chronic cough. Otolaryngol Head Neck Surg. 2006;135(1):17-21. doi:10.1016/j.otohns.2006.02.003