Gastroesophageal Reflux Disease (GERD) is a chronic digestive condition where stomach acid or contents flow back up into the esophagus. While often associated with heartburn, GERD can also cause symptoms outside of the esophagus, known as extra-esophageal symptoms. A persistent cough is a common, yet often overlooked, sign of GERD. GERD is estimated to cause 10% to 40% of chronic cough cases, defined as a cough lasting eight weeks or longer.
The Mechanism of Reflux-Induced Cough
The cough associated with GERD often results from Laryngopharyngeal Reflux (LPR). LPR occurs when stomach contents travel past both the lower and upper esophageal sphincters, reaching the sensitive tissues of the throat (larynx and pharynx). Since the throat and vocal cords are more delicate than the esophageal lining, even a small amount of stomach acid or enzymes like pepsin causes significant irritation.
This irritation triggers a cough reflex through two main physiological pathways. The first is a direct injury mechanism, where aerosolized acid physically contacts the larynx and trachea, causing inflammation and triggering a protective cough. The second is an indirect reflex mechanism: acid in the lower esophagus stimulates the vagus nerve, creating a reflex arc between the digestive system and the airways.
LPR is often called “silent reflux” because it frequently occurs without the typical GERD symptom of heartburn. The refluxed contents irritate the upper airway without lingering long enough to damage the esophagus. A weakened upper esophageal sphincter allows stomach contents to flow backward, causing inflammation and a chronic cough.
Characteristics of a Reflux-Related Cough
A reflux-related cough often has specific qualities and timing that distinguish it from coughs caused by asthma or infection. This cough is typically dry and non-productive, meaning it does not bring up mucus or phlegm. It is also persistent, lasting for many weeks or months without responding to standard cold or allergy treatments.
The timing is a telling sign, as the cough frequently worsens after eating or when lying down, when reflux is more likely. The supine position allows contents to flow upward easily, often causing coughing fits at night that disrupt sleep. Individuals may also experience a chronic need to clear the throat, a sensation of a lump in the throat (globus sensation), or hoarseness.
Chronic throat clearing and hoarseness are strong indicators of LPR. However, many people with a reflux-induced cough do not experience classic heartburn symptoms. This absence of typical GERD symptoms is why the diagnosis of a reflux-related cough is often delayed or missed entirely.
Confirming the Diagnosis
Diagnosing a chronic cough potentially caused by GERD or LPR requires ruling out other common causes, such as postnasal drip, asthma, and certain medications. Initially, a healthcare provider may suggest a trial of acid-suppressing medication to see if the cough improves, though this is not always definitive. Specific testing is often required for a more objective diagnosis, especially when the cough is the only symptom.
Ambulatory reflux monitoring, including 24-hour pH-impedance monitoring, is one of the most accurate diagnostic tools. This test uses a thin catheter inserted through the nose into the esophagus to measure both acid (pH) and non-acid reflux events over a full day. The impedance component is useful for detecting weakly acidic or non-acidic reflux episodes common in LPR that may contribute to the cough.
A laryngoscopy is another procedure used to confirm the diagnosis, where a physician uses a flexible scope to visually examine the throat and vocal cords. The doctor looks for physical signs of irritation or inflammation, such as swelling or redness, consistent with exposure to stomach contents. While visual evidence is suggestive, 24-hour monitoring provides objective data on the frequency and nature of reflux events.
Treatment Focused on Cough Resolution
The primary goal of treating a GERD-related cough is to reduce the frequency and severity of reflux episodes, eliminating the irritation that triggers the cough. Treatment typically involves a combination of medication and targeted lifestyle adjustments. Acid-suppressing medications, such as Proton Pump Inhibitors (PPIs) and H2 blockers, are the pharmacological first-line treatment.
PPIs work by significantly reducing the amount of acid produced by the stomach. For LPR-related cough, these medications may need to be taken at a higher dose or for a longer duration, sometimes for several months, before improvement is achieved. If acid suppression alone is insufficient, prokinetic agents may be added to help increase the tone of the esophageal sphincter and accelerate stomach emptying, reducing the chance of reflux.
Specific lifestyle modifications are equally important for resolving the cough, as they directly address the physical causes of reflux. Elevating the head of the bed by six to eight inches, using blocks or wedges, utilizes gravity to prevent nighttime reflux from reaching the throat. Avoiding meals within two to three hours of lying down is an effective strategy to ensure the stomach is empty before sleep.
Dietary changes focus on eliminating trigger foods that can relax the esophageal sphincter or increase acid production. These triggers often include:
- High-fat or spicy foods
- Chocolate
- Caffeine
- Citrus fruits
- Alcohol
Maintaining a healthy body weight and avoiding tight clothing around the abdomen can lessen pressure on the stomach, reducing the likelihood of reflux and chronic cough.