Sensory Neuropathic Cough (SNC) is a chronic cough disorder that is thought to have a neurogenic cause. SNC1 is also sometimes referred to as a cough caused by “laryngeal sensory neuropathy,” or is sometimes grouped within the more general category of “refractory chronic cough.”
Symptoms of Sensory Neuropathic Cough
A person with SNC may cough dozens to hundreds of times per day, often also waking up at night to cough. A few of these daily coughing attacks may become violent and last 30 seconds to several minutes. The person’s eyes may tear up and the nose may run; the person may gag or throw up; the person may leak urine, or worse; a few of our patients have even broken one or more ribs during a violent coughing attack. A key characteristic of SNC is that a coughing attack is typically, though not always, preceded by an abrupt sensation in the throat; this sensation may be described as a “tickle,” a “sudden dry patch,” “like inhaling a powdered doughnut,” “dripping mucus,” or something else.
Bruising from SNC
This individual occasionally coughs to the point of hoarseness. Particularly noteworthy is the subglottic bruise (arrow, dotted line) caused by profound Valsalva-retching kind of coughing. The rest of the right cord (left of photo) is also bruised. See more images →
Possible Explanation for SNC
SNC is thought to be a relative to neuralgia, like post-herpetic neuralgia (persistent pain long after an outbreak of shingles has resolved), or even diabetic neuropathy (“I feel bees stinging my feet”), except that the sensations felt by SNC patients are not painful.
With SNC, it may be that the nerve endings in a person’s throat have become damaged, so that they “misfire” and cause this cough-provoking tickling or similar sensations.
Treatment for SNC
Many individuals with SNC have found relief through use of a neuralgia medication, such as amitriptyline 2, desipramine 3, gabapentin 4, pregabalin, oxcarbazepine, and others. These kinds of medications may help to reduce or abolish a person’s coughing by diminishing the nerve-ending “misfires” caused by SNC.
In our experience, patients sometimes need to work through more than one of these neuralgia medication options, at varying dosage levels, before they arrive at a satisfactory degree of relief. Another treatment option that can be tried is capsaicin5. For more about treatment, see our second video (SNC: Medications) below.
Frequently Asked Questions about SNC
What Causes SNC?
Nobody knows for certain what causes SNC. We have a number of patients whose SNC began soon after a shingles outbreak in the throat. Others began to cough not long after thyroidectomy or other neck surgery. A very large number describe the beginning soon after an upper respiratory infection—usually a memorable one.
Suppose we could prove that SNC/ laryngospasm was caused by a viral injury. In that case, it would not be seen as a continuing infection, but instead as a chronic neural injury. Think, for example, of the post-herpetic neuralgia that can be permanent after a shingles (herpes zoster) outbreak. Treating with antivirals, say a few months after the infection and after the neural injury had occurred would not be expected to heal the damaged nerve endings. Or an extreme example just to send the point home: If a person lost an arm due to the “flesh-eating” streptococcus, treating for streptococcus a month after the loss of the arm (and resolution of the infection) would not restore the arm.
Viruses often seem to have a kind of “tropism.” Ever notice how some upper respiratory infections spread through a family, and seem to have highly similar effects? Everyone starts with scratchy throat, then the nose runs, then the cough starts. Etc. One solution could be a “virus” shared by three family members that had similar effects on all of them.
If sensory neuropathic cough were in fact a virus-induced neural injury, then it would be possible that more than one member of a family could develop SNC. It is interesting that I have many patients whose mother, or sister, etc. also have SNC. Did they share a virus? Or is it a genetic “susceptibility” in families?
How do I Find a Doctor for SNC?
Call the otolaryngology (ENT) department of a nearby university or other large medical center. Ask to speak to the triage nurse. Ask that nurse if there are one or more doctors there who have a special interest in neurological coughing. You may need to make a few different phone calls to find a doctor in your area known to have this particular interest.
If you can’t find any such doctors, you might also try calling the pulmonary departments of nearby universities or large medical centers. Or, alternatively, you might simply share the information you found about sensory neuropathic cough with your primary care physician and ask, “Could I please try low-dose amitriptyline?”
As a last resort, you would of course also be welcome to come to our office in the Chicago area. After that first visit, Dr. Bastian would (if your diagnosis is indeed sensory neuropathic cough) be able to manage your treatment from a distance. But of course, for most people it’s not possible to travel so far.
Can SNC Resolve on Its Own?
SNC can resolve slowly over months in some people. But the best plan is not to wait (and suffer) but instead to be treated with an SNC medication mentioned above.
What Is the Role of Tramadol or other Narcotics like Codeine for SNC?
Most patients respond to first-line treatments such as amitriptyline, gabapentin, venlafaxine, capsaicin spray, or targeted nerve blocks (e.g., pretracheal or superior laryngeal nerve injection of triamcinolone/mepivacaine). However, a subset of patients continue to suffer from severe, life-disrupting cough despite these therapies.
In such cases, tramadol—a synthetic narcotic often better tolerated than codeine—can provide significant relief. About half or more of these patients experience cough suppression. While our preference is always to use medications that address the underlying neurological disorder rather than simply quieting the symptom, SNC can be so debilitating that tramadol may be a reasonable option.
Some patients use it only occasionally—for example, to gain a night of uninterrupted sleep or to take a “holiday” from coughing. In the most severe cases, a small minority may use it on a more regular basis. The key is to individualize therapy, weighing risks and benefits for each patient.
For us, tramadol remains a last-resort option, though other physicians may view its role differently.
How do You Tell if You Have SNC, Initiated by Covid-19?
- Each episode of coughing, whether lasting seconds or minutes, begins with a sudden ZING sensation. (Examples: a sudden tickle, or abrupt “dry patch” that demands that you cough even though you aren’t sick or producing mucus commensurate with the magnitude [violence or duration] of your cough. Other sensations might be a sudden dripping sensation, pinprick, feeling like a sudden popcorn kernel, etc.)
- Coughing is often spontaneous and unexplained, but if you do certain things, you are more likely to cough. Talking, a loud laugh, taking a deep breath, trying to sing in upper voice, posture change (especially getting into bed at night or rolling to a certain position), a very strong odor, etc. makes it more likely that you will cough.
- Cough “frequency” and “severity” are out of proportion to any illness or any mucus produced. What mucus is produced may be the RESULT rather than the CAUSE of coughing. In other words, you begin to produce mucus only after hard coughing for 10 or more seconds (If I force myself to cough hard just as an experiment, I produce mucus too!).
What would a person do if he or she suspects they may now have SNC, with Covid-19 as the cause of the nerve damage?
- Find a peer-reviewed but open source journal article that will describe SNC and how it is treated. Print and take that article to your doctor.
- Ask your doctor: “Would it be a problem for me to just try amitriptyline or gabapentin (etc.)?” What do I hope you can avoid by doing these things? Being told “Oh, this is just how it goes with Covid-19,” when you actually now have SNC, which is treatable …
- And if you strike out with your doctors, call nearby large ENT groups and ask “Does any of your doctors treat sensory neuropathic cough?”
- Or engage a Laryngopedia teleconversation.
Keep pushing the medical system to help you, because imprecisely treated SNC can be debilitating!
What About Botox for the Treatment of SNC?
While Botox is an excellent treatment for other voice disorders such as spasmodic dysphonia, we consider it a last-line option for SNC. The mainstay treatment remains neuralgia medications, which have consistently shown better results.
In our experience, Botox can help a small subset of patients with SNC, but its benefit is often limited. Moreover, it carries a notable downside: a weakened voice, especially during the first weeks after injection.
For these reasons, we keep Botox on the list and will provide it at any patient’s request, but in our opinion it should remain a “last option” rather than a standard recommendation.
What Are the Visual Indicators of SNC?
About 30% of individuals with SNC—a condition usually understood primarily as a sensory disturbance or dysesthesia that triggers coughing—also demonstrate subtle motor findings suggestive of neurogenicity.
In this subgroup, voice evaluation may reveal a slight, jittery instability on sustained phonation. Laryngoscopic examination may show tiny quivering movements or asymmetry of vocal fold motion. Normally, the folds move in perfect synchrony, functioning as mirror images of each other, much like the symmetric blinking of the eyes. In roughly one-third of patients with SNC, however, this mirror-image synchrony is diminished or lost.
The majority—about 70%—have an entirely normal-appearing examination. Yet even in the 30% with motor findings, the abnormalities are often subtle but definite, and therefore easily overlooked. For this reason, a normal laryngeal examination does not rule out SNC.
Can Bronchorrhea (mucus production) and Cough Both Be Due to Neurogenic Mechanisms?
The key is to determine whether the bronchorrhea is the cause or the result of coughing. If mucus production occurs right at the onset—say, within the first one or two coughs of a many-cough episode—then mucus may be the trigger. But if mucus only appears after 20–30 seconds of hard, repetitive coughing, often accompanied by watery eyes (oculorrhea), runny nose (rhinorrhea), and similar reflexive secretions, then the “mucus” is more likely a consequence of the coughing itself. Try forcing yourself to cough vigorously for 30 seconds—you’ll probably be surprised at what secretions you produce.
For more detail, see my article: When mucus seems to be causing your cough or throat clearing, but isn’t.
As for the coexistence of primary bronchorrhea (from asthma, COPD, etc.) and sensory neuropathic cough (SNC): if a patient describes a stereotyped sensation (tickle, etc.) that always precedes the cough by a split second, it’s reasonable to consider SNC therapy—especially when the “usual suspects” (allergy, reflux, asthma, post-nasal drip, etc.) have been treated with no success.
Finally, in the older pediatric population, don’t forget the possibility of nonorganic cough. In those cases, it is often the coughing behavior itself that is stereotyped, more than the sensory disturbance that initiates it.
Sometimes I Cough so Hard that I can’t Breathe—My Throat Feels like it’s Closing up and I’m Gasping for Air. Is that Something Different?
That might be a laryngospasm, a sudden closure as the muscles in the larynx contract in a spasm. These can be terrifying—making it difficult to breathe or speak—but they have never been fatal.
One method to manage laryngospasms is what we call “straw breathing,” breathing slowly through pursed lips, as though you’re sucking through a straw.
Though laryngospasms are something different than sensory neuropathic cough, they are often related. A severe bout of coughing can often induce a laryngospasm.
I Keep Getting Diagnosed with Acid Reflux, Asthma, and Allergies by Different Doctors. I’ve Gone Through Endless Tests and Treatment Trials Without Benefit. I’m Skeptical About Trying Yet Another Process, This Time for Sensory Neuropathic Cough.
What you’re describing is something I call “medical jadedness.” It often happens when well-intentioned doctors who don’t know about SNC keep ordering tests or treatments that don’t help, leaving patients exhausted and discouraged.
Please don’t give up. The key difference here is that sensory neuropathic cough is a nerve-based condition. Relief typically comes only from medicines that calm the irritated nerve endings—not from reflux pills, inhalers, or allergy therapies.
Even once you are on the right path, finding the best medication still requires patience and sometimes trial-and-error. In our experience, about 4 out of 5 patients improve with the first or second neuralgia medication tried. Once both the correct diagnosis is made and the right medication is found, lasting relief becomes possible.
Will These Medications Cure Me of Sensory Neuropathic Cough / Sensory Neuropathic Throat Clearing, or Will I Have to Take Them Indefinitely?
The honest answer is: we don’t know until we try. Some people who have been coughing for many years may ultimately need to stay on medication long term. But here’s how we approach it:
- Step 1: First, we find the medication and dose that brings substantial relief—at least a 70% reduction in coughing, throat clearing, and even laryngospasm. We call this “good control.”
- Step 2: After a month of stable control, we suggest “tiptoeing out of the room to see if the monster wakes up.” In practice, this means gradually lowering the dose to test whether symptoms return.
- Step 3: If symptoms increase, the patient resumes the full dose and holds that stable relief for about 3 months before trying again.
If after two or more careful taper attempts the cough or throat always returns, it usually means the medication will need to be continued indefinitely. That said, patients are always welcome to re-try tapering at any point in the future.
I Had a Respiratory Infection (cold, bronchitis, sinus infection, etc.) but Even Though I Am no Longer Ill, the Cough Hasn’t Really Gone Away. This Happens Every Time I get Sick—I Keep Coughing and Throat Clearing Long After the Infection Is Gone. Is it Still Sensory Neuropathic Cough if it Eventually Goes Away After a Few Months?
Yes, this pattern can represent an “episodic” variant of SNC. In this form, each upper respiratory infection is followed by a lingering cough that lasts weeks or even months, even as much as 3 or 4 months in some cases, before it finally disappears. After an interval of little or no coughing, the cycle repeats with the next infection.
In this situation, starting a neuralgia medication during the active infection usually won’t help right away. These medicines (such as amitriptyline or gabapentin) only work when they are treating only the “tickle” and not the infection itself. Most say SNC treatment begins to work about 2 weeks after tURI is over. At that point, they can shorten and lessen the “tail” of post-infectious sensory neuropathic cough.
The typical strategy is to use medication for a month or more, until the SNC cough “tail” is over, then taper off until the next SNC coughing tail is triggered by a new URI.
By contrast, patients with continuous SNC (cough present all year, not just after infections) often—but not always—need to stay on medication long term.
Is Sensory Neuropathic Cough (SNC) Hereditary?
Some people with SNC say they are the only one in their family with chronic cough or throat-clearing problems, while others report that a parent or sibling has the same issue. So while SNC is not considered strictly hereditary, it does sometimes appear to “run in families,” much like certain skin conditions.
For example, some families are prone to dry winter skin, rosacea, or eczema—though not every family member is affected, and not always in the same way. In a similar, and somewhat speculative sense, certain families may share a greater vulnerability to developing SNC.
What Is the Differential Diagnosis for Sensory Neuropathic Cough (SNC)?
I have argued that SNC is essentially a prima facie (“obvious on the face of it”) diagnosis: when the history matches the classic features, no other disorder needs to be ruled out first. Not to mention that by the time a correct SNC diagnosis has been made, often the disorders below have already been ruled out. In my own practice, if the patient clearly fulfills the criteria for SNC, and the cough has been present for a year or more, I do not feel it is necessary to exclude other conditions.
That said, if one were to list conditions occasionally considered in the differential—more for discussion than for action—they would include:
- Non-organic cough – most often seen in adolescents, usually with a perfunctory or predictable pattern.
- Cough-variant asthma – typically suspected early but lacks the characteristic triggers and sensory disturbances of SNC.
- Chronic bronchitis – generally associated with smoking or environmental exposures.
- Pneumonia – usually obvious due to systemic illness and radiographic findings.
In practice, when the syndromic criteria for SNC are present, these alternative diagnoses are generally easy to distinguish on history alone.
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Audio · Chronic cough · Cough · Coughing disorders · Disorders · Photos · Sensory Neuropathic Cough (SNC) · VideosTable of Contents
Audio Examples of SNC + SNTC
Some aspects of these patients' experiences are atypical; not all patients have the same experience with SNC.
Patient Coughs 300x per Day!
This middle-aged man has suffered from a severe coughing problem for 15 to 20 years, and it has become more severe over time. At first visit, he was coughing an estimated 300 times during waking hours, and twice during sleep.
Each cough is typically initiated by a sudden “patch of sandpaper” sensation in his throat or a dripping feeling. Common triggers include eating, singing, and even touching the sternal notch area, which reliably provokes coughing. Most daytime episodes last about five seconds and are aggressive, but once each day he experiences a severe, exhausting coughing fit that lasts up to two minutes.
During these more severe episodes, his face turns red, his eyes water, he nearly vomits, and he struggles to breathe. He has consulted five physicians and undergone bronchoscopy, 24-hour pH monitoring, esophagoscopy, pulmonary function testing, and allergy evaluation—all of which were normal. Allergy medications, asthma inhalers, cough suppressants, expectorants, antibiotics, acid reflux medications, and steroids, provided no benefit.
He limits his speaking, avoids public events, and often sleeps alone due to the frequency and violence of his coughing.
Patient Interview with Gabapentin (Neurontin)
This retired teacher tells her story, and how after trying treatments for “the usual suspects” (allergy, acid reflux, and asthma) without benefit, gabapentin has given her a 70% reduction of her problem, which she finds enormously satisfying.
Learn more: Gabapentin or Pregabalin for SNC or Throat Clearing (SNTC)
Patient Interview with Amitriptyline (Elavil)
Prior to taking amitriptyline this woman had been on the usual asthma inhalers, antibiotics, antihistamines, nose sprays, acid reflux medicines, and cough suppressants with no benefit. Of her estimated 25 episodes of coughing per day, about 5 per day and 1 per night were aggressive, lasting at least a minute.
During those bad episodes, her nose ran, she almost threw up, and almost passed out. Her eyes teared up, she lost urine, and she often saw stars. The sensation that begins all of this was a tickle or sudden dry sensation at the level of the larynx. The patient limited talking and slept alone so as to not disturb her husband. She reports here what amitriptyline has achieved for her.
Patient Explains Common “Triggers” of SNC
This woman has just been diagnosed with sensory neuropathic cough. She illustrates the concept of “triggers.” That is, while most people with SNC say that coughing episodes are usually spontaneous, many have discovered things that make it more likely to cough.
For example, one patient said “I can’t sing ‘Happy Birthday’ to my grandchildren.” Another said, “I carefully avoid taking a deep breath, because every time I do that, I cough.” Other common triggers are talking (vibration), breathing warm or cold air (change of temperature), touching a spot on the neck (pressure). Here, the triggers she illustrates are singing and taking a deep breath.
Patient Explains the SNC Sensation
This elderly man had a tracheotomy performed in the context of a life-threatening illness. The tracheotomy tube has been removed but he continues to experience abrupt tickling or “sudden phlegm” that causes him to either cough or aggressively throat clear many times a day.
At least ten episodes per day are aggressive, lasting 2 minutes. He turns red and nearly passes out.
Here, he describes the sensation associated with his cough and throat clearing.
Interview with an SNC Patient
Note: some aspects of her case are atypical.
This woman is a “best case scenario” of treatment of SNC. Low dose amitriptyline has given her “miraculous” benefit, after coughing for ten years and failing to benefit from treatment of “usual suspects” (allergy, acid reflux, and asthma).
At first hearing, one might think her story is too good to be true. But at the end, she makes a statement about what happens if she discontinues the amitriptyline….
Sensory Neuropathic Throat Clearing (SNTC)
This man has struggled with coughing and throat clearing for 36 years. The abrupt sensation he describes is “paper fluttering” in his throat. He is in the midst of an episode during this interview.
Photo Essays of SNC
A collection of photo essays demonstrating SNC in various patients:
SNC “Injuries”
Given the aggressiveness of sensory neuropathic cough episodes in many individuals, one might expect vocal fold injuries—such as swelling, bruising, or contact granuloma—to be common. Surprisingly, such injuries are only observed in a small minority of patients.
Informally, it appears that aggressive but purely percussive coughing is not especially injurious. More often, injury seems to arise when coughing is accompanied by a grinding vocal noise—resembling retching or forceful throat clearing. In some patients whose cough involves extreme “Valsalva-like” effort, petechiae may even appear in the face or nasopharynx, or subconjunctival hemorrhage may occur.
Still, even among those who cough in this more vocally strenuous manner, overt vocal fold injury remains surprisingly uncommon. Below are examples of such unusual injuries.
Bruising from Sensory Neuropathic Cough
Closer view of bruise (2 of 2)
Bruise caused by violent coughing (1 of 2)
Example 2
Bruise from coughing (1 of 3)
Pre-phonatory instant (2 of 3)
Phonation (3 of 3)
Hemoptysis
SNC patient (1 of 6)
Panoramic view (2 of 6)
Lidocaine (3 of 6)
Carina (4 of 6)
Right mainstem bronchus (5 of 6)
Left mainstem bronchus (6 of 6)
Videos about SNC
SNC Medications + Treatments
This is a newer discussion of sensory neuropathic cough, based in a caseload of (surely) well over a thousand patients. The attempt is to touch upon the major points:
- Explanation of “damaged nerve endings” as the cause;
- The futility of allergy, acid reflux, and asthma treatments;
- The unfrutiful “chasing of mucus;”
- The use of medications that calm down damaged, jittery nerve endings;
- And a brief description of the many current treatment options.
Capsaicin Spray for Treatment of SNC & SNTC
One option for sensory neuropathic cough and sensory neuropathic throat clearing is capsaicin, the substance that makes hot peppers hot.
Sustained use can deplete a neurotransmitter in the mucosa of the throat called substance P, thereby diminishing the number and severity of episodes. Some use it as a powerful counter-irritant to try to shorten the duration of coughing.
A third group may use it as a “cough scheduler: This group has learned that after inducing a hard attack with capsaicin, they may have an hour or more free of coughing, during which they can complete a social event. This video explains the various capsaicin “strategies” in detail.
Still Coughing After COVID?
In this video, Dr. Robert W. Bastian explains three explanations for coughing in the context of Covid-19 infection, with emphasis on the potential for sensory neuropathic cough (Phase 3).
SNC, Part I: Coughing That Won’t Go Away
Sensory neuropathic cough is a chronic cough condition that does not respond to the usual treatments. Many individuals who have been coughing for years find relief from treatment with “neuralgia” medications.
SNC Part II: Medications
Dr. Bastian continues from SNC, Part I and introduces potential medications to treat sensory neuropathic cough.
Audio Only
Phantom Phlegm!!
Patients with Sensory Neuropathic Cough (SNC) comment on feeling mucus drip down their throats, but often…it isn’t there!
Additional Resources
View additional information about SNC on our website:
A Journal of Observational Laryngology Entries
You May Not Have to Live with that Chronic Cough
Clinical Diagnosis of Sensory Neuropathic Cough (SNC) via Syndrome-Matching
Gabapentin or Pregabalin for SNC or SNTC
Sensory Neuropathic Cough Need Not Be a Diagnosis of Exclusion
Treatment for Sensory Neuropathic Cough
Medical Jadedness and Treatment of Sensory Neuropathic Cough
A Trail to Sensory Neuropathic Cough
The Use of Capsaicin for Sensory Neuropathic Cough
Still Coughing After COVID-19?
When Mucus Seems to Be Causing Your Cough or Throat Clearing – But Isn’t
SNC Publications
Bastian RW, Vaidya AM, Delsupehe KG. Sensory neuropathic cough: a common and treatable cause of chronic cough. Otolaryngol Head and Neck Surg. 2006; 135(1): 17-21. [1]
Jeyakumar A, Brickman TM, Haben M. Effectiveness of amitriptyline versus cough suppressants in the treatment of chronic cough resulting from postviral vagal neuropathy. Laryngoscope. 2006; 116: 2108-2112. [2]
Bastian ZJ, Bastian RW. The use of neuralgia medications to treat sensory neuropathic cough: our experience in a retrospective cohort of thirty-two patients. PeerJ. 2015; 3:e816. [3]
Ryan NM, Birring SS, Gibson PG. Gabapentin for refractory chronic cough: a randomized, double-blind, placebo-controlled trial. Lancet. 2012; 380(9853): 1583-9. [4]
Hoesli RC, Wingo ML, Wajsberg B, Bastian RW. Topical capsaicin for the treatment of sensory neuropathic cough. OTO Open 2021; 5: 2473974X211065668. [5]