Chronic Cough and Reflux: Causes, Symptoms, and Treatment Options

You’ve had your cough checked out by the doc, but it still isn’t going away. It might be related to reflux—even if you don’t have heartburn. The good news: it can be managed.  

Reflux as a Cause of Chronic Cough 

In adults, a chronic cough lasts at least eight weeks. That can seem like a lifetime because not only is a constant cough annoying, it can be painful, disrupt your sleep, be embarrassing at times, and impact your overall quality of life. It’s important to keep in mind that a sour taste in your mouth, hoarseness, and throat pain may precede a chronic cough. It pays to be aware of any of these other symptoms. Schedule an appointment for your cough and report symptoms to your physician.

What’s the Link Between Reflux and a Cough?

If you’ve had other causes for a chronic cough ruled out, maybe it’s time to consider that it might be related to reflux. Gastroesophageal reflux disease (GERD) affects millions of people worldwide. For many, heartburn is the telltale symptom that leads them to the doctor’s office for a diagnosis. But not everyone experiences GERD the same way. Some people have a nagging cough, but no heartburn. In fact, in those who do have a chronic cough, 75% of the time, there may be no GI reflux symptoms at all.

Ongoing coughs attributed to GERD may not receive as much attention as heartburn, but studies suggest that 10% to 60% of chronic cough cases may be caused by reflux. An epidemiological association between GERD and chronic cough is also found in people of all age groups. The condition even has its own acronym: GERC (gastroesophageal reflux-induced chronic cough).

What Causes Chronic Cough?

Tobacco use is one of the most common reasons for a chronic cough, although there can certainly be other causes, such as allergies and lung disease. Aside from these reasons, a lingering cough typically has three main causes (or a combination thereof):

Post-nasal drip: Also called upper airway cough syndrome, it can be caused by reflux or by laryngopharyngeal reflux (LPR),  sometimes called “silent reflux”. With LPR, the acidic stomach contents reach the upper esophagus and throat, leading to hoarseness and cough, without the chest discomfort typically associated with acid reflux or GERD. 

Asthma: Studies indicate that 30% to 80% of people with asthma experience reflux.

GERD: Even though GERD is a well-known cause of chronic cough (the link between the two was discovered in 1966), it’s not always easy to diagnose. It requires the elimination of other probable causes, which can take some time.  

How Reflux Can Trigger Coughing

There are a few ways that reflux contributes to GERC: 

Direct stimulation (“reflux theory”): Acidic reflux liquid coming back up the esophagus and throat can stimulate cough receptors directly. The damage caused by repeated reflux could also lead to mucus release, which then activates cough receptors. Another aspect of reflux theory is the microaspiration of fine droplets of the acidic liquid into the lungs.  

Indirect stimulation (“reflex theory”): Repeated aspiration of reflux substances may stimulate the vagus nerve and trigger coughing even without any direct contact between the airway and the reflux liquid. The airway may also become hyperresponsive, and coughing is more likely to occur. 

Esophageal Dysmotility: Disruption in the ability of the esophagus to move food to the stomach, resulting in prolonged acid exposure and more frequent respiratory symptoms. The fact that coughing contributes to loss of tone in the lower esophageal sphincter certainly doesn’t help, either. It allows more acid to back up and leads to a miserable cycle of reflux and coughing.

Strategies for Managing Chronic Cough Related to Reflux

Successful resolution of chronic cough typically involves both lifestyle modifications and medical treatment to reduce reflux and alleviate symptoms.  

Lifestyle and Dietary Modifications

The lifestyle modifications for addressing GERD-related chronic cough are essentially the same as they are for GERD:

• If you smoke, quit

• If you’re overweight, lose weight

• Raise the head of your bed a few inches

• Wear loose-fitting clothing 

• Avoid trigger foods (such as alcohol, carbonated beverages, spicy, acidic, or high-fat meals)

• Eat smaller meals

• Quit eating 2-3 hours before bedtime, and stay upright after meals

Over-the-Counter and Prescription Medications

You may have already tried over-the-counter medicines for your cough, such as cough syrup or throat lozenges. But while those medicines may make you feel better temporarily, they don’t address any underlying reasons for your cough. If your doctor does find that reflux is related to your cough, you’ll move on to a prescription medication specifically to decrease reflux. Medications for acid reflux fall into a few categories: proton-pump inhibitors, histamine-2 blockers (H2 blockers), and antacids. 

Bottom Line:

The chronic cough conundrum can be frustrating to say the least! Consider keeping a log of symptoms and their progression, along with any other health or diet issues that may be related (including heartburn, laryngitis, sore throat, etc). Sharing information like this can provide clues that help you and your healthcare provider get to the bottom of the issue more quickly.  

1. _{Brown, J., & Shermetaro, C. (2022, December 19). Laryngopharyngea reflux. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519548/}

2. _{Chang, A. B., Lasserson, T. J., Gaffney, J., Connor, F. L., & Garske, L. A. (2005). Gastro-oesophageal reflux treatment for prolonged non-specific cough in children and adults. The Cochrane database of systematic reviews, (2), CD004823. https://doi.org/10.1002/14651858.CD004823.pub2}

3. _{D'Urzo, A., & Jugovic, P. (2002). Chronic cough. Three most common causes. Canadian family physician Medecin de famille canadien, 48, 1311–1316.}

4. _{Gaude G. S. (2009). Pulmonary manifestations of gastroesophageal reflux disease. Annals of thoracic medicine, 4(3), 115–123. https://doi.org/10.4103/1817-1737.53347}

5. _{Goyal, M., & Nagalli, S. (2022, November 27). Esophageal motility disorders. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562155/}

6. _{Grandes, X. A., Talanki Manjunatha, R., Habib, S., Sangaraju, S. L., & Yepez, D. (2022). Gastroesophageal Reflux Disease and Asthma: A Narrative Review. Cureus, 14(5), e24917. https://doi.org/10.7759/cureus.24917}

7. _{Irwin R. S. (2006). Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines. Chest, 129(1 Suppl), 80S–94S. https://doi.org/10.1378/chest.129.1_suppl.80S}

8. _{Irwin, R. S., & Richter, J. E. (2000). Gastroesophageal reflux and chronic cough. The American journal of gastroenterology, 95(8 Suppl), S9–S14. https://doi.org/10.1016/s0002-9270(00)01073-x}

9. _{Lucanska, M., Hajtman, A., Calkovsky, V., Kunc, P., & Pecova, R. (2020). Upper Airway Cough Syndrome in Pathogenesis of Chronic Cough. Physiological research, 69(Suppl 1), S35–S42. https://doi.org/10.33549/physiolres.934400}

10. _{Wu, J., Ma, Y., & Chen, Y. (2022). GERD-related chronic cough: Possible mechanism, diagnosis and treatment. Frontiers in physiology, 13, 1005404. https://doi.org/10.3389/fphys.2022.1005404}