May 20, 2024

I Have A Dry Cough All Day, What Can I Do?



  • Most people with chronic coughs have respiratory reflux, but that cough is “wet,” that is, it is productive. You cough up mucus and have post-nasal drip. A chronic dry cough is different.
  • Dry cough that occurs every day but never at night and without a pattern is usually a Neurogenic Cough. The problem is due to cough (Vagus) nerve damage, usually caused by a virus.
  • Characteristics of neurogenic cough are that it is stimulated by talking, singing, laughing, fumes, and/or ambient temperature changes.
  • Drugs that can affect nerve function, such as amitriptyline and gabapentin, are usually effective and can cure neurogenic cough when used properly.

Join Facebook Live with Dr. Jamie Koufman the 1st Wednesday of the Month at Noon Eastern Time; and if You Have Questions About Respiratory Reflux Ask Them There. And If You Miss It Live, It Gets Posted to YouTube Afterwards.

Dry cough and wet cough are neurogenic and reflux-related coughs, respectively. Many people with neurogenic cough also have reflux cough, but those with neurogenic cough alone represent only about 10% of people with chronic cough. This post about dry cough is about Neurogenic Cough, which is a kind of “sick-nerve syndrome,” most often caused by a viral infection. The problem is with the Vagus Nerve Part I. This is a three-part article; here are links to Part II and Part III

What Does Neurogenic Mean?

Neurogenic means “nerve-caused.” Here are two examples. Imagine I touch your shoulder, and you say, “Ouch.” You feel my soft touch as painful; that is neurogenic. It suggests that sensation from the shoulder is perverted and that the nerve shoulder is sending the wrong message to the brain. 

Another example is that of a soldier who has his foot blown off in war, but two years later, he is complaining of foot pain but has no foot. That means that when the severed nerves tried to heal, the wires got crossed; crossed wires commonly cause neurogenic symptoms. Neurogenic is nerves behaving badly.

What Are the Symptoms of Neurogenic Cough

First, an overarching distinction: chronic cough can be divided into pulmonary and non-pulmonary categories, and unlike reflux-related cough, neurogenic cough is non-pulmonary. It virtually never involves the lungs or associated lung disease. With a neurogenic cough, the dry cough never rattles (mucous in) the throat, and nothing is ever coughed up. It occurs any time during the day without any pattern, and it is not associated with respiratory reflux symptoms.

Notably, reflux cough has a different pattern. Typically, the cough occurs after eating, when lying down, bending over, and at night. Again, it is a “wet,” productive sputum cough, often first thing in the morning and after eating. And, reflux cough at night can also be associated with terrifying choking episodes, Laryngospasm, awakening the sufferer from a sound sleep. 

I mention this because people with true neurogenic cough do not have those symptoms. Neurogenic cough is strictly a daytime phenomenon. That said, a big group overlaps, meaning those people have both reflux-related and neurogenic cough and symptoms of both. 

An uncomplicated neurogenic cough is a dry cough that bothers you all day, often for no apparent reason. It can, however, be triggered by speaking, singing, laughing, talking on the telephone, going in and/or out of air conditioning, and especially by fumes, e.g., automobile exhaust, burnt toast, and perfume. 

What Causes Neurogenic Cough?

Coughing is a strictly vagal event, which means that the sensation “I feel like I need to cough” and the action of coughing itself both come through the vagus nerve. Therefore, it’s not surprising that anything that can damage the vagus nerves, such as a tumor, trauma, or infection, can cause or lead to a neurogenic cough,

The most common cause is a virus. The vagus nerves run right under the lining membrane of the throat behind the tonsils, and a virus can infect them, leading to neuropathy, a “sick nerve syndrome.” While there are other other causes of neuropathy, viruses are the most common, leading to a diagnosis of Post-Viral Vagal Neuropathy.

How Is Neurogenic Cough Treated?

Over the course of my career, I have treated perhaps 20,000 patients with chronic coughs. That’s a lot of people, and over the course of time, I have refined my approach. But when all is said and done, I have found the most effective treatment is a combination of amitriptyline (Elavil) and gabapentin (Neurontin). 

Amitriptyline is an old-time antidepressant called Elavil, but the amount that I use (5-10 mg) would not make a fly happy. The purpose of the amitriptyline is to make gabapentin work well, perhaps better at smaller doses. In other words, the combination of drugs works better than either alone. 

Gabapentin has been used for all kinds of nerve-related problems, such as diabetic pain. I recommend starting it on small, pediatric doses. That way, people rarely experience side effects. If the dose is increased rapidly, some people can experience memory problems, such as word retrieval; but that said, untoward effects vanish after the dose is decreased or the medicine is stopped … is my experience.  

To start, I recommend breaking the 10 mg pill in half. Take 5 mg per day, if no issues, increase to 10 mg per day, always taken at bedtime.  A few days later, you can start gabapentin in 100 mg doses that escalate every few days until a dose is found that stops the cough. Just improving the cough alone is not enough; you have to get the cough stopped for a therapeutic effect. 

I have already written a post on the Treatment of Neurogenic Symptoms in my practice. Here Is a PDF that you can share with your physician. It lays out the dose schedule I recommend and how to escalate safely.

If I Have Neurogenic Cough, How Long Do I Need Treatment? 

There’s something you need to know. Once you have reached the therapeutic dose and have no cough, treatment needs to be continued for at least six months to a year. The thinking is that over time, there is a re-set in the vagal control center in the brain … but it takes time. If you stop too soon, the cough will most likely return at some point.

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