Treatments: Chronic Cough

This page describes how chronic cough is treated, from addressing common causes to therapy for cough that persists.

Most chronic coughs (lasting longer than 8 weeks) improve once the cause is found and treated. Because more than one cause can be present at the same time, treatment is often done in steps, adding or adjusting therapies based on how the cough responds. This page describes the main treatment approaches. The condition itself is described on the chronic cough conditions page.

Step One: Finding and Treating the Underlying Cause

Most chronic coughs in adults come from a small number of common conditions. Treatment usually starts by targeting the most likely cause, based on the person's history, exam, a chest x-ray and sometimes breathing tests. If one treatment does not fully work, another may be added, since several causes can overlap.

Acid Reflux (Gastroesophageal Reflux)

Stomach acid backing up into the throat and airway can trigger coughing, sometimes without any heartburn (see reflux). Treatment often focuses on lifestyle measures first, described further on the reflux diet and lifestyle page:

• Losing weight if overweight

• Raising the head of the bed

• Avoiding meals within 3 hours of bedtime

For people who also have heartburn or regurgitation, acid-reducing medicines (such as proton pump inhibitors, H2 blockers, antacids or alginates) may be added. Cough from reflux can take up to 3 months to improve, so patience is needed. Acid-reducing medicine alone is generally not used for people who have no heartburn or regurgitation, because it is unlikely to help the cough in that situation. More options are on the reflux treatments page.

Postnasal Drip (Upper Airway Cough Syndrome)

Mucus dripping from the nose or sinuses down the back of the throat is a very common cough trigger. This is often treated with nasal sprays, antihistamines or other allergy and sinus medicines aimed at reducing the drainage and irritation. See nose and sinus treatments.

Asthma (Including Cough-Variant Asthma)

Sometimes a lingering cough is the main or only sign of asthma. This type of cough usually responds to inhaled corticosteroid medicines. Occasionally the inhaler itself can irritate the airway and trigger coughing; using a spacer device, switching the type of inhaler or a short course of oral steroids may help in those cases.

Medication Side Effects

Certain medicines can cause a chronic cough. The best known are a class of blood pressure medicines called ACE inhibitors (names often end in "-pril," such as lisinopril). A diabetes medicine called sitagliptin has also been linked to cough. When one of these medicines is the suspected cause, a clinician may consider stopping it to see whether the cough goes away. This is done only under a clinician's guidance, with a suitable replacement when needed.

Smoking and Irritant Exposures

Tobacco smoke and workplace or environmental irritants are important and treatable causes. Quitting smoking and reducing exposure to irritants are key first steps.

When the Cough Continues: Refractory or Unexplained Chronic Cough

In some people, the cough continues even after a thorough evaluation and treatment of the usual causes, or no clear cause is ever found. This is called refractory (treatment-resistant) or unexplained chronic cough. It is thought to involve oversensitive cough nerves, so the airway reacts to things that would not normally cause coughing. Two main approaches are used, sometimes together.

Cough-Suppression Speech Therapy

This is a non-drug treatment delivered by a speech-language therapist, usually over a few sessions. It combines:

• Education about the cough and what triggers it

• Techniques to control and suppress the urge to cough

• Breathing exercises

• Vocal hygiene and staying well hydrated to reduce throat irritation

• Counseling and support

The goal is to reduce throat irritation and help a person gain more voluntary control over the cough. Studies have shown it can lower how often and how severely people cough and improve quality of life, with no significant side effects.

Neuromodulator Medications

These are medicines that calm overactive nerves. They were originally developed for other conditions such as nerve pain, but they can help quiet an oversensitive cough. Options a clinician may consider include:

• Gabapentin or pregabalin

• Low-dose morphine

• Amitriptyline

Because these medicines can cause side effects, such as drowsiness, dizziness, confusion, dry mouth, blurred vision, fatigue or constipation, they are usually started at a low dose and increased slowly as tolerated. The benefits and risks are discussed before starting and are reviewed regularly (for example, monthly) to decide whether to continue. Extra caution is used in people with COPD. Sometimes speech therapy and a neuromodulator are combined when either one alone is not enough.

When Specialist Evaluation Is Used

Most chronic coughs can be managed by a primary care clinician. Referral to a specialist, such as a lung doctor (pulmonologist), an ear, nose and throat doctor (otolaryngologist) or a dedicated cough clinic, is generally considered when:

• The cough does not improve despite a full evaluation and adequate treatment

• There are warning signs ("red flags") such as coughing up blood, unexplained weight loss or other concerning symptoms

• Further testing is needed to look for less common causes, such as a foreign object in the airway, lung disease or problems with swallowing and aspiration

Specialists have access to additional tests, such as CT scans, bronchoscopy, nasal endoscopy, fiberoptic laryngoscopy and reflux testing, and to the full range of treatments for hard-to-control cough.

Key Points

• Most chronic coughs improve once the cause is identified and treated.

• Common and treatable causes include reflux, postnasal drip, asthma, medication side effects, and smoking or irritant exposure.

• More than one cause can be present at once, so treatment is often added in steps.

• When cough persists or has no clear cause, speech therapy and nerve-calming medicines can help.

• Specialist evaluation is used for coughs that do not improve, for warning signs or when further testing is needed.