A Journal of Observational Laryngology

Clinical observations, anecdotes, and insights which other clinicians may want to consider and test with further research.

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A Trail to Sensory Neuropathic Cough

By Robert W. Bastian, MD

A new clinical insight can be sparked when a physician encounters a series of patients in close succession whose stories overlap in some surprising way. This is an account of that sort, reviewing a trail of patients that led to understanding the clinical entity of sensory neuropathic cough. ((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.))

Before the late 1990s, when the fourth patient described below opened for me a new thought window and initiated a substantial caseload of sensory neuropathic cough, only an occasional patient—not more than one or two per year—would ask for help with a chronic cough of a diabolical, life-changing sort. Examination would reveal nothing to explain the cough. If not already done by a prior physician, some tests and then empiric treatments would follow. The focus was always on the “usual suspects”: allergy, acid reflux, and cough-variant asthma.

Nothing ever worked for prior physicians or for me, until I saw the following four patients within a few weeks of each other and a new concept appeared: coughing initiated by a primary neurogenic sensory disturbance, analogous to neuralgia.

Story One: Amitriptyline for Post-Herpetic Neuralgia
This woman was a longtime patient. She had a lively personality, matched by her hair color which, at the age of 68, she kept a vibrant red. Several years earlier, I had performed a supraglottic laryngectomy for cancer. She had been doing well for a number of years afterwards, and was here for a long-interval appointment. We caught up with the events of her life, and I examined her and pronounced all to be well.

Then she asked, “Could you look at my ear? It is really bothering me.”

I looked, and based on early findings and perhaps a single blister-like lesion, said to her, “I think you might be just at the start of shingles” (Herpes zoster oticus, in this case). A dermatologist confirmed the diagnosis and began treatment.

I didn’t see her again until her next six-month cancer follow-up. Within the visit, I inquired about her ear, and examined it. The bowl of her ear appeared healed, but scarred. She told me she was still suffering with ear pain, and that she was taking amitriptyline. “It definitely helps,” she said, “but I wish it did more.”

Story Two: Amitriptyline for Gagging as a Cousin Sensation to Neuralgia
The new patient questionnaire of the man in front of me said he was an electrician, 42 years old. His facial expression and other body language said “introvert.” After a handshake, introductions, and a sentence or two of pleasantries, I asked, “How can I help you?”

“I’m gagging,” he said, and looked at me.

“You’re gagging?” I asked, hoping he would elaborate. He only nodded “yes,” continued to look, and waited.

I followed with a series of questions. Each question was answered in a few words:
“If I touch my neck, it makes me gag.”
“I can’t button my shirt.”
“I have a hard time shaving [this part of my neck].”

After these kinds of answers, here was the look again, expectant, hoping that I would understand. But I didn’t. “May I touch your neck?” I asked.

He paused, as though considering, and then said, “If you want to.” I reached out and touched the front of his neck with one finger, at the level where a buttoned collar would meet. His response made me wish I had first asked him if he had just eaten. Five seconds is a long time to aggressively gag and heave.

When he finished, there again was the look of expectancy. My mind flitted through some different possibilities.

Could this be someone who has lived his whole life at the extreme end of the continuum of the gag reflex? I’d learned early in my career that, at one end of the gag reflex spectrum, there are some people who would be naturals as sword-swallowers. At the other end of the spectrum, I once saw a man who began to gag whenever I asked him to open his mouth, before I had even raised my tongue blade to within two feet of his lips.

But a hyper-gag reflex wasn’t the explanation. “No,” he said, “I’ve only had this for six months…. No, I never had trouble at the dentist before this started.”

My mind turned elsewhere. Might this be in some way behavioral? This man struck me as utterly grounded and low-maintenance, and I already believed this interaction completely, but I had to double-check. So, without asking again, I reached out and touched his neck again—same response, and again, entirely believable.

But then, my mind moved to a third idea. This has to be a neurological disorder. My touch to his neck had demonstrated a trigger phenomenon, as one sees in persons with neuralgia. And like neuralgia, the response was a sensory disturbance, but the difference was that, rather than pain, it was a gagging sensation.

Almost apologetically, I asked this man, “Would you mind trying a medication that might help?” The response was immediate: “Sure.”

I prescribed amitriptyline, at low dose, as I might for neuralgia. I didn’t hear from him for a few months, and so asked a nurse to follow up by phone. True to form, the information that came back was cryptic. “He says thanks. It worked.”

Story Three: Amitriptyline for a Non-painful, Non-coughing Sensory Disturbance
Her demeanor was “elderly,” and she was also large. I remarked inwardly how well she looked and how remarkable to live to age 75 at her weight. After introductions I asked my usual, “How can I help you?”

She said, waving to indicate her throat, “Oooh, doctor, I get a dry patch.”

Now, “dry throat” is not an uncommon symptom for which people seek an explanation and relief. So my mind went initially to things like medication side effects, Sjögren’s syndrome, and even insufficient fluid intake.

But answers to my subsequent questions did not fit those scenarios. The sensation was more than simple dryness. “It’s like the Sahara Desert,” she said at one point. Furthermore, the sensation happened suddenly and episodically, a few times a day. In fact, on a ten-point scale, the sensation was an instantaneous “8” for several seconds and then subsided to a much lesser severity for maybe another ten seconds before it went away completely.

Two things had caught my attention and made me slow down, circle around the problem, double-ask some questions in slightly different words, and listen deeply. First, she had said at one point, “When it happens, I just jump up and run to the kitchen for a glass of water, but it doesn’t help. Jump up and run was said with emphasis and rising pitch. I had a hard time visualizing this particular woman either jumping or running. I felt compelled to understand this choice of words.

The second thing that caught my attention was her gesture. Her left hand indicated a specific place low in the left side of her neck. “Right here,” she said. She hadn’t used the fingers, thumb, and even palm as “dry throat” patients do to indicate the whole of the throat. Instead, she had done a two-finger point to a specific place. And when I asked her several minutes later to tell me again where the sensation was, she pointed to exactly the same place.

“I have a medication I’d like you to try,” I said. It was again amitriptyline, at low dose. (Today I’d give desipramine instead in her age group or, depending on response, gabapentin, citalopram, capsaicin spray, or other “neuralgia” medications.)

The response? After eight months of having struggled with what she viewed as a terrible problem, she obtained marked relief, even with the first dose of medicine.

Story Four: The Lights Turn On… Amitriptyline for Sensory Neuropathic Cough
(A few details below elaborated on from other similar patients, to give an “idealized” scenario)
This 46-year-old woman was desperate. Her chief complaint wasn’t a voice, swallowing, or breathing problem, such as for virtually all of my other patients. Instead, she was struggling with a cruel cough. In fact, for the past twelve long years, coughing had become a daily way of life for her.

In recent years, the problem had become more severe. She said she coughed hundreds of times every day, and it awakened her from sleep once or twice every night. Many episodes lasted only a second or two. She had stopped even noticing a lot of those.

About six times a day, the cough was much more aggressive and lasted an estimated 45 seconds. “I cough out a lung,” she said. “I turn red, my eyes tear, my nose runs, and I nearly (or occasionally do) throw up.” These episodes were humiliating when they occurred in public. “I once had someone come over to me in a restaurant and insist on giving me the Heimlich maneuver,” she said. “My husband practically had to fight him off.”

She further elaborated that she had to carry a spare pair of underwear due to occasional urinary incontinence. And to avoid a “scene” in public, she sometimes had to step away during church, a committee meeting, or when at the movies. Another problem was that she felt exhausted much of the time, because of her interrupted sleep.

I was only the latest in a long line of prior physicians. She estimated that she had seen eight or ten physicians, including one or more pulmonologists, allergists, gastroenterologists, and ENT physicians.

She had undergone numerous tests and all were completely normal or marginally abnormal. She had been treated, re-treated, and double-treated for asthma, even though she had no family history of this, and didn’t know what it was to feel short of breath, wheezy, or to have any chest symptoms. She was dutifully following doctor’s orders and using a steroid inhaler, though she hated it because each use tended to provoke an episode of severe coughing.

She had also tried allergy medication and treatment for acid reflux, again without having had the usual symptoms for either of these conditions—other than her cough. None of these medications worked either. Courses of oral steroids helped transiently, and codeine gave her longer spans of uninterrupted sleep. Still, in her mind, nothing was really working.

The arresting piece of information was that each episode of coughing was initiated by a sudden, compelling tickle. She could point to the location with one finger—exactly in the sternal notch. The sensation was the same every time—stereotyped. The only variation was that before the prolonged and violent episodes of coughing, the sensation was particularly urgent.

Just as for my gagging electrician, and for my “running and jumping” septuagenarian, the word “neurological” entered my mind. This cough was the result of a sensory disturbance. The resulting cough was not solving a problem, such as mucus that needed to be expelled, or infection, or responding to inhaled powdered sugar while eating a donut. Instead, this cough was the problem, caused by a primary sensory disturbance like neuralgia. In fact, for several years afterward, I would call this disorder “cough neuralgia,” before settling instead on “sensory neuropathic cough.”

I began to explain to this patient the concept of a neurogenic cough, and that I wanted her to try amitriptyline. She looked a little uncertain, possibly because my first-ever formulation was clumsy. Or perhaps it was because she had been told so many times that this was allergy, or acid reflux, or cough-variant asthma and was having trouble putting those diagnoses aside. Or perhaps it was because she was medically jaded. Who wouldn’t be, after all that she had been through, including visits to faraway and famous centers of expertise?

Amitriptyline doesn’t work for everyone (a second or third medication usually does in that case). Thankfully, amitriptyline did for her. She called the office two days later. “I slept through the night for the first time in 12 years,” she reported. After some additional tweaks and adjustments, she arrived at her final dosing strategy. She still coughs occasionally but only rarely violently. She also remarked that “my husband and co-workers are amazed.”

Sensory Neuropathic Cough Today
From that patient to the present, I look for chronic cough patients whose episodes are initiated by an abrupt and stereotyped sensation of tickling, sandpaper, pinprick, or the like. As is the case for neuralgia, many notice not only spontaneous attacks, but also some that are triggered: by talking, singing, taking a deep breath, touching a spot on the neck, breathing in cold air, changing position (such as when lying down at night), or encountering smoke or strong odors. Most patients describe a frequency, violence, and duration of coughing dramatically out of proportion to the other symptoms (if in fact any are present) of asthma, acid reflux, or allergy.

I rarely see patients with sensory neuropathic cough first, but if I did, I would not necessarily order any of the tests or treatments for allergy, acid reflux, or asthma. If a patient’s history matched sensory neuropathic cough well, and especially if the cough had been present for years, I would use professional judgment and common sense to individualize. In most cases, I would proceed directly to treatment for sensory neuropathic cough, without delay or sidetracks to “usual suspects.”

By now I have seen many hundreds of sensory neuropathic cough patients, several every month. An explanation of a primary neurogenic form of coughing is still new to all of them. I spend a great deal of time elaborating and drawing parallels to neuralgia, diabetic neuropathy, and the like. I caution them about medical jadedness so that they don’t give up in disgust if the first medication I recommend doesn’t work. And not everyone gets perfect results. Still, I’m thrilled whenever I meet another cough patient who I believe will find long-awaited relief, thanks to the surprising trail I was taken on by four patients many years ago.


Bastian ZJ, Bastian RW. (2015) The use of neuralgia medications to treat sensory neuropathic cough: our experience in a retrospective cohort of thirty-two patients. PeerJ 3:e816 https://dx.doi.org/10.7717/peerj.816

38 thoughts on “A Trail to Sensory Neuropathic Cough

  1. Dr. Bastian, I read your article “A Trail to Sensory Neuropathic Cough” this evening with disbelief. The lady in story Four describes me exactly. Nineteen years ago, the office I worked in came down with a nasty bronchitis bug and I was affected. After a round of antibiotic, the bronchitis went away, but not the cough. I didn’t think much of it for the first month or so after, but eventually, the force of the coughs started to affect my daily life – more so, I was embarrassed to come down with a “fit” when I was in public. People thought I was dying – coughing up a lung. Some people would look at me in disgust thinking that I should not be out in public with such a nasty cold.

    My doctor at the time thought it sounded like asthma and put me on the regular medications, including Advair. These did absolutely nothing and, as the lady in your article, often provoked the coughing. I took asthma meds for seven years and finally asked for more tests as it felt that my cough was getting worse. I was sent for allergy tests. The tests showed NO ALLERGIES to anything. I asked the allergist what was causing my cough, and he said he had a suspicion that is was something spastic larynx or vocal chord dysfunction. He referred me to an ENT.

    The ENT simply looked down my throat, but not with a scope and agreed it sounded like what the Allergist suggested and referred me to a speech therapist.
    I have seen three different speech therapists with no relief. My current doctor has tried me on three different proton pump inhibitors including Omeprazole, Pantoprazole and Rabeprazol. The last one helps with my occasional heart burn but does nothing for the coughing. I was sent for a full respiratory assessment and asthma was completely ruled out.

    I had a barium swallow which the technician ruled out GERD. I also saw another ENT recently who determined that there is nothing wrong with my vocal chords and declared that I don’t have Vocal Chord Dysfunction either. He is now referring me to a Pulmonologist. My GP is setting up the appointment but feels that this will not result in any clear diagnosis either. He is at his wit’s end and I know I certainly am.

    It has gotten to the point that I worry about driving because I will have fits sometimes while driving that are so harsh that I see stars after and it takes a few seconds to focus again. My eyes well up with tears and my face turns red. Even my husband, who is used to the continual coughing, was very worried over a fit I had just a week ago in which I doubled over and couldn’t catch my breath, including gasping for breath and nearly passing out. I had to go lay down until I could breathe normally again.

    I am going to print out some of the info from your site and ask my doctor to watch your videos. I am worried about taking more medicine as I have been taking 75mg of Effexor XR for about 20 years. I also take Telmisartan for high blood pressure. I have quit taking it a few times over the years just to see if that would stop my coughing, as I read that BP meds can cause coughing. I’ve also just started Angeliq (Drospirenone and Estradiol) because of menopausal symptoms. I’m 51 years old. I hope that you can also give me further advise or suggestions for my doctor.

    I am encouraged by what I have read about Laryngeal Sensory Neuropathy and for the first time in a long time have hope that taking Amitriptyline might also help me.

    Sandy Nolette

    • Thank you for taking the time to tell your story. Though I cannot of course offer a diagnosis in this format, your story is entirely classic for sensory neuropathic cough. I also cannot give treatment advice without knowing you, so consider what follows to be orienting information that you could discuss with your personal physician. Please also consider reviewing quite a lot of other information you can find on our website. In particular, there are two teaching videos on sensory neuropathic cough (https://laryngopedia.com/sensory-neuropathic-cough/#videos) and the second one contains a lot of information about medications.

      Our strategy might be to begin with amitriptyline 10 mg 2 hours before bed, and then to titrate upwards either until you get at least 80% reduction of your cough problem, or until you begin to run into unacceptable side effects. These side effects are mostly grogginess in the morning especially, and dry mouth. There can be effects on blood pressure, glaucoma, etc. but we actually rarely run into them. As for compatibility with other medications, I tend to just prescribe this medication routinely and make sure that it is filled at the same pharmacy as other medication. Pharmacy computers are best for interactions. Early on, I got many phone calls from pharmacies saying “there is an interaction with this patient’s xyz medication.” Then I began to tell patients to point out that this medication can be effective at a very low dose in some people. I also suggested asking “is this a red flag interaction, or just a yellow one?” Since adopting these strategies, I get relatively few calls from pharmacies any more.

      Even if amitriptyline is a “red flag,” take heart. That’s because our next medication on the list is gabapentin, and that works with most other medications. Occasionally, the need to manage the cough trumps the need to take the other medication, such as your Effexor, and under doctor’s advice, a patient will discontinue the other medication if only for a week or two, just to answer the question about the potential for amitriptyline.

      There are many tweaks and adjustments that can be tailored to an individual’s specific circumstance. The main point is to persist and persist until you have taken every step necessary to diminish the terrible, life-changing problem! Please keep going!

      -Dr. Bastian

      • Hello and I must say I was so excited when I found this article! I have been searching for months about my condition and usually all I see when I search is neck pain or cancer associated with it which aren’t me. I have been to a speech therapist who had concerns and sent for a barium test which showed nothing unusual. This has been so hard dealing with! Over the last year I have noticed that if I move or bend my neck a lot of times I start violently coughing and almost gagging. I have thrown up before because of this. Also, it sees to be triggered at times just from eating..actually the swallowing part or just breathing in air. It seems to last for several weeks and then taper down for a few days then come back. I have had several attacks of laryngiospams(SP?) also. Those started first around late 30’s and I haven’t had one in years but it had happened @10 times or so. Now it’s this crazy cough!!! I don’t have mucus, it’s not allergies, and I can feel when it’s going to happen usually a split second before and it occurs in the base of my throat. I do have diabetes 2 (about 10 years) hidradenitis suppurativa (10 years) also I am a smoker, dx’ed with Sjogren’s (which led to a bad posterior nose bleed and surgery) -small fiber neuropathy-and fibromyalgia all within a year or so and still no explanations for the electric like shocks throughout my body head to toe constantly among many other things I don’t wan to bore you with. I feel like my life went down hill literally since I turned 40 and would like to scream at times. Just hearing this could possibly be related to many things I already have makes me happy. I have a feeling most of what I have is related but cant prove it all yet and am so frustrated! If you think this is possibly worth talking to my doctor about, I will pass it along! My nerves are really getting on my nerves!

  2. Dr. Bastian~ Your article “A Trail to Sensory Neuropathic Cough” was a God-send to my mother who has suffered with her chronic choking cough for many years. I am hoping/wondering/asking if there are non-prescription alternatives, in pill form, that could be taken in place of the prescription drugs mentioned in the article? ~Kari

    • I think the best way to look for alternative is to search diabetic neuropathy as I have read that the same medication used for laryngeal sensory neuropathy are the mostly the same as for diabetic neuropathy. Therefore do your own search. I have found some great websites. Some herbal oils recomended along with R- alpha lipoic acid and acetyl- l- carnitine vitamin B6 and finally most importantly vitamin B12. The one that I would use is methylcobalamine with high dose or Mercola´s B12 spray despite the fact that I am unsure of the claims he makes. Also lion mane mushroom seems hopefull as it does something to nerve regeneration. I am young and have suffered from mucus in my throat for more than a decade. I have developed dryness in my throat despite the fact that my singing voice has improved with training my throat problems are incredible. despite the good voice It is very unstable and I feel mucus dried in the bottom part of my vocal cords and this has been proven during singing. And now after all my exams I have finally realized that laryngeal sensory neuropathy fits exactly in mojority of my symptoms. I have wondered why even during short singing I start to cough and during prolonged I need to spit tons of mucus. I have found myself in all symptoms Dr. Bastian states. Also with neuropathic cough you can experience some symptoms like mucus buildup in throat after drinking water either warm or cold and even starts coughing. I would point out something that Dr Bastian does not mention in his video and that is huge amount of mucus in throat and need to constantly swallow thick mucus that just can not be swallowed entirely and in couple of seconds after swallowing you get that feeling of a need to swallow mucus and you decide to spit it rather in order to prevent another quick buildup. I have my own theory that mucus in that case is caused by cinstant firings of sensory nerve endings in laryngeal mucosa. So other words said neurogenic imflamation of the tissue and hence laryngeal submucosal glands are activated by parasympatic nerve fibers the abnormal functionality of nerve fibers causes changes in viscosity of mucosa and also in quantity. this means thicker mucus anyway. I don´t know if I am right but according to my feeling in my throat, laryngeal sensory neuropathy causes the larynx to be drier than normal. This may be the difference between Sjogrens and LSN hence in LSN your pharynx would be wet enough but your throat would feel dry. And that dryness may be most tangible in subglottic larynx, the bottom part of vocal cords. I have this proven in my case. and when coughing mucus arises after the period. I am so glad that Dr. Bastian have such a good clinical experience with this misery condition. I have search to explain my symptoms and went through all differential diagnosises to only find no visible cause. A week ago I stumbled upon the concept of neuropathic cough or hypersensitivity cough which are not exactly the same things but are treated eqaully. In two weeks I have a scheduled appointment with my neurologist (fisrt visit in my life) and I will bring forward some clinical studies and articles by Dr. Bastian and after visit I will send her a videos in email.

      • I competely cured sensory neuropathic cough by taking acetyl l carnitine- three times a day approximately 1 mg for three weeks. Now the cough has not come back for half year. Still the dryness of throat has remained.

        • Hello

          That’s really good to hear. I was in Bastian’s clinic and I am still taking amitryptiline. I rarely cough anymore, however I still feel stuff on the right side of the lower throat or upper esophagus and feels weird when swallowing. The only physical finding there is a diverticulum in scanners which still needs to be investigated to find out what it is.

  3. I too am Patient Four! For over 20 years I have had a chronic cough – just as your patient and the woman who commented…sadly, this too has been my life! I am 56 years old and this cough has had such a negative impact on my quality of life. I cough hundreds of times per day – sometimes I just have the urge to clear my through but mostly they are serious coughing fits. I too have seen pulmonary specialists, ENT, Allergists, chiropractor, primary care physicians, etc. Have had all the tests and have tried all of the meds for asthma, cough variant asthma, allergies, GERD, COPD. One doctor felt that I should see a psychiatrist. NOTHING has worked. My tickle has gotten worse over the years and I had just about given up that I would cough myself into an early grave….then a couple of weeks ago, I Googled “Mystery Cough” and I found your research and info. I read it and started to cry I was so relieved and happy as I know I have Sensory Neuropathic Cough. I have an appointment this week with a ‘Cough Specialist’ in the Boston area. Tomorrow I am dropping of info about your findings and am asking him to PLEASE look at it or just watch your videos. I don’t care what the side affects of the medicines are…I just want to stop coughing. THANK YOU SO VERY MUCH!!!!!!!

    • MaryLou,
      I echo your post! I too was asked if everything was “OK” in my marriage and life in general…and that perhaps I should consider a psychiatrist because there was no medical reason they could find. The relief, albeit just 1 week out of 13 years, is so beyond gratifying. I could not be more happy to have a day without a choking cough.

  4. I have been coughing, sometimes violently, for nearly 13 years now; yes 13. I have been through all the standard specialists: ENT, Allergist, Gastro, Pulmo and GP. Having gone through annual series of trials of Endoscopies to treat GERD (which was negative), I had a Bravo probe inserted to measure acid reflux. It proved negative yet I was told to try Nexium, Zantac, Omeprazole, Prilosec, etc. No relief.
    I was placed on inhalers of all sorts from Advair, albuterol and then onto another I forget; no relief. Prednisone exacerbated the cough to epic proportions. Basically, without detailing each failed attempt at reducing my violent and daily coughing fits, after 13 years I was giving up (again).
    2 months ago, I was told about hearing about *this* sensory neuropathic cough treatment with amitripyline. So, after going to the neurologist and begging to try *this* 10mg dose (because what else do I have to lose), I can say that I am experiencing my first week of significant cough reduction in 13 long suffering years. I couldn’t walk down a hallway, read a book to my kids, laugh without choking, sip water without going into a severe fit. My kids have never known me as a non-coughing person but I think I might have found the absolute miracle and treatment to establishing normalcy!
    I’m almost afraid to say anything in fear that the cough will return with a vengeance. But, a week of relief without hourly hacking? I am so beyond grateful that I was told about Dr. Bastian, amitrityline and the previous success stories which I can now gladly say I contribute to.
    The suffering from the cough was unbearable and was adversely affecting many aspects of my daily life. As quickly as it started back in 2002, it has quickly been reduced at least 90% and I will take that! THANK YOU SO VERY MUCH!
    Ninon O’Neill

    • I feel like rather a novice!! i have had my cough for just under 3 years and its driven me to distraction!! it has affected every aspect of my life, from socialising, exercise, talking on the phone!! I too have had all the above mentioned tests and im sick of it! I cant wait to see my local GP and show him these printouts! for the first time i really believe there is hope of a life without a permanant cough!! Thank you so much DR Bastian, for your research, you have many grateful sufferers!! I will post here again when i have recieved treatment to let you know how it goes. I cant wait to have my appointment with my GP, Im sooooooo excited! 🙂

  5. Hi Dr. Bastian,
    Thank you for providing all this great information!

    My question is that if this sort of condition is caused by a neuropathy or some sort of oversensitisation of a nerve, can it ever be fully healed? Does the use of amitriptyline or gabapentin usually help to heal or ‘reset’ it (so that you can eventually come off these medications), or is it likely that someone would have to stay on them forever just to maintain their improvement – and go back to square one without them?

    Have you known patients who have taken these medications for a course of a few months (or however long), and then been free of their cough/condition, without an ongoing need for medication?
    In short: Can someone ever be free of this condition entirely, or will it always require maintenance and supression through medication?

    Thank you so much, in advance!

    • Thank you for your question. The answer is “yes” to all of the possibilities. I have seen people who have coughed for many years as a way of life, who got sustained and high level (nearly complete or complete) relief from coughing. After a month or two like this, they tapered gradually off of the medicine and the cough did not return. I don’t think this is as common, however, as the person who may experience this success, but then a URI comes along and re-awakens the “monster.” They then have to resume medication at least for some months. So our perspective is that, when you get excellent relief for a long time, try tiptoeing out of the room. If the monster definitely “stirs” and coughing begins to increase, then you titrate back up to full dose. If not, then continue the taper to nothing. Some can get off of medicine permanently or intermittently, but many need to take it indefinitely. My first gabapentin patient is still on it after more than 15 years.
      (Please consider this informational only, not medical advice; don’t act without your personal physician’s input.)

      • Hello

        I really wonder what makes the difference to respond to the medication or not.
        Some people seem to cure and remain symtom free, others might find relief while being on the medicine and others might not even respond at all.

        I really wonder what makes the difference for such variable response.


  6. I have been suffering for 15 years from irritating cough. I am not a smoker or a drinker. Did all tests including colonoscopy, endoscopy, etc. I saw ENTs, allergists and gastro physicians. I’ve been prescribed drugs for acid reflux, allergy, asthma. None is helpful. I live in Miami area, Florida, and I was wondering if you can recommend a physician who can find out if I suffer from the so-call neuropathic cough. Thanks,

    • Unfortunately, Dr. Bastian doesn’t know the doctors in your area well enough to make a recommendation, as to which doctor to see about this. However, he suggests that you do the following to find such a doctor:

      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.

      We hope you find that information helpful. Please consider it informational only, and not medical advice. Don’t act without your personal physician’s input.

  7. Dear Dr. Bastian, I was so relieved to finally understand what is happening to me. I have coughed for almost 30 years. I have done most of, if not all asthma and allergy treatments throughout these years with no relief. One of my asthma doctors actually reprimanded me for complaining to him that the treatments haven’t helped this chronic cough. He told me: “you’re asthmatic, what do you expect?” The only temporary relief I had was putting a clove under my tongue which caused some numbness in my throat, subsiding the cough for a bit. I was so desperate that I did this every day and night for the past 5 years. I had lost all hope. All areas of my life are affected. When I am in a public place, I always position myself by an exit door incase I have a cough attack. Sometimes I avoid public places altogether. I carry a plastic bag in my car incase I cough to the point of vomiting. People are always either trying to help me or avoid me, thinking I have something contagious. I am exactly like you described and what I’ve heard in the testimonials. I knew that what I have is not an allergic reaction, although I have allergies and asthma. I am certain beyond any doubt that I have sensory neuropathic cough. I have collected all the information and will see a neurologist on Monday. I hope she listens to me because it is my only hope. I am so grateful for your research and I hope it works for me. Thank you

  8. Dr. Bastian,
    My 16 year old son was recently diagnosed with Laryngeal sensory neuropathy. It took quite a while to get this diagnosis, as it was masked by chronic sinus infections (resolved with surgery)and then GERD and LPR. Also, my son does not have the chronic cough, but he has continual throat clearing, ear /jaw pain and itchy and swollen sensation in throat and tongue. We had been to 8 different specialists to rule out many reasons for the swollen sensation, all tests were negative. The pain in jaw, neck and tongue, itchy feeling in throat ,tongue and nose fluctuate. Have you had any patients who present with all these symptoms without the cough? He is to start on Lyrica next week. Thank you.

    • Debra,
      I just found this page last night and it gave me some hope. Did you find anything to ease or correct your son’s condition?
      My 17 year old daughter has suffered with this condition you have described since she was 9. We have seen several doctors, ENTs, and was even sent to a children’s hospital to be scoped from throat down to opening of small intestine. She’s been diagnosed with Gerd, allergies, asthma, and anything else they can think of. Nothing has helped her. One of my friends who used to take Elavil for migraines said that it numbs the nerves in the throat. Which was what I was researching when I came across Dr. Bastian’s website. I am still searching and hopeful for anything. I would appreciate any replies.

  9. Sorry to hear about your son. Throat clearing initiated by a sudden sensation of tickling, “mucus,” etc. can be closely related to SNC. The sensations your son describes could all be neuropathic, and therefore empiric trials of lyrics, or amitriptyline, etc., are not unreasonable. If these sensations are continuous/ constant, the “match” for SNC, laryngospasm, and sensory neuropathic throat clearing are not as good…but this sort of trial could still be appropriate. (I hope you find this information helpful. Please consider Dr. Bastian’s reply to be informational only, and not medical advice; don’t act without your personal physician’s input.)

  10. I’m so happy I found this information! In one of your videos, you mentioned the cough (that lasts a month or so) following a viral infection to be a subset of SNC. Do you go through the same treatment protocol for this as for someone who coughs every day? I believe that is what I have, with the exception of chronic/daily mucus production and throat clearing. Either way, the only way to stop the cough I get is through a combination of prednisone and Hydromet syrup, which is pretty extreme for a cough, but nothing else works!

  11. I cannot believe I am reading this.
    I have lived with a very debilitating cough for four years following an everyday cold which left me with a chest infection antibiotics. After eight weeks I felt fully recovered but my cough remained. I had a chest X-ray at that time and another two years later, when my cough was becoming progressively worse. Both X-rays suggested my chest was clear with no disease.
    The cough is extremely debilitating and effects my quality of life in a number of ways, leading to occasional incontinence, severe gagging, vomiting and embarrassment.
    I now take inhaled steroids (which always triggers a coughing bout) and salbutamol, I have also been using Omeprazole with some slight improvement for the last six months.
    About a year ago I had a very painful neck injury with nerve involvement in my right arm. After various other analgesics proved inadequate I was prescribed Amitriptyline.
    Thankfully it really helped to manage the pain but in addition my cough stopped completely within 24 hours. I thought it was coincidence and have not spoken to my GP about this miraculous effect-I really thought I was imagining it. I’m no longer taking Amitriptyline as my neck is now much improved and, not surprisingly, my cough has returned and is now as troublesome as ever.
    I read your article last night and decided to take an Amitriptyline 10mg tablet, which I had kept since my neck injury, before going to bed. It worked. Today I am cough free. I am ecstatic. My next task is to see my GP and convince him that this is genuine and that Amitriptyline would be an appropriate treatment. Wish me well.


  12. Thank You so much for this information. I feel I have been diagnosed!!! I have coughed my WHOLE LIFE and I am 52 years old. My mom said she used to sit outside with me in the winter to try to give me relief from my cough. Of course that didn’t help, nothing has! I have had every test, taken all kinds of meds. seen every Dr. trying to get HELP! Nothing has worked. I go into a coughing fit when I laugh really hard, walk outside in cold weather, after I eat-esp. chocolate, when I first get out of the tub or shower. My nose runs and yes sometimes I have accidents with urination. I have coughed so hard I throw up. I attend to contact my family Dr. in just a few minutes and make an appointment to see if he can get me started on one of the meds you have recommended. This cough has caused so many embarrassing situations in my life. The only medicine I ever got relief from was tussinex, but that makes me feel so loopy and also that can become additive.
    Again thank you so much.

  13. Hi Your website really helped my with my chronic cough! Without it I would never know what was wrong! I struggled for a year not sleeping and constantly coughing!
    I have a few questions about medications and if in the future will my symptoms will eventually go away? I am on Mirtazapine for the cough and it has helped me pretty well but the cough has not fully gone away.
    Would the medications you listed be better?
    Will I be able to sing again as I really love to sing and I have not been able to since the cough started?

  14. One of the comments mentioned excessive mucous — or at least the feeling of excess mucous on the cords. Even after a long vocal warm up, I still have a scratchy sound and the sensation on gunk on my cords. Is this part of SCN?

    I’ve been taking citalopram for years — and have no idea if this has had any impact on my coughing. Switching to beta blockers made a huge difference though.

    Is the capsaicin spray you mention a nasal spray? Is there a brand or a level of capsaicin you recommend?

    Thank you. I’m relived to have information about my sudden coughing g attacks.

    Kitty >^..^<

  15. I am so glad I found this site. I was looking for information about coughing that comes just before attacks of dry heaving (retching) and vomiting. Might anyone be able to point to any information about this please? I’ve had no luck as of yet.

    I have had episodes nausea and vomiting (usually lasting hours and sometimes occurring daily for a month) for years. I also have a chronic migraine condition, and I do sometimes experience migraine-related nausea and vomiting. But lately, I am getting nausea and vomiting without pain too! It’s very frustrating. I was recently diagnosed with IBS (type C), and put on amitriptyline. This medication worked very well for the severe abdominal pain I was having, and it seems to also work for the nausea. But if I miss a single dose, I tend to get even worse vomiting! Why might this be? Is that a withdrawal effect? Do I really have IBS or is it something else? I’ve read that IBS doesn’t usually cause such severe nausea (or can it?) Do I need to be on the amitriptyline (ami) for life?

    I’ve lost too much weight lately (because I still feel like I can’t eat much, even when on the ami), and my blood potassium level is low. My blood pressure also seems on the (perhaps too) low side. I love that the ami has given me pretty good pain reduction, and somewhat good nausea reduction, but it comes at a price: I am often very fatigued during the day, and I feel really lightheaded when getting up quickly. Sorry for the long note, I’m just so tired of being sick and I would do anything to get better! As a graduate student, these health problems have caused me to fall greatly behind and I’m very worried whether I can even stay in grad school. It’s my dream to do environmental research, but I feel like I can no longer keep up because I’m just too sick. I also feel misunderstood by most around me – they minimize my challenges, yet I feel absolutely crippled most days. Please help, if anyone can. Thank you so much. And I wish everyone visiting this page success in finding a good doctor that will help.

  16. Hello,

    I have been researching neurogenic cough here and there for the past year. I have an odd issue that I can’t seem to find case studies for online. Your Study 4 above describes me very accurately with one significant difference — I tend to get sick (upper respiratory) in the spring, and a horrible, unforgiving cough follows for about 3 months, but then it goes away on its own. This has happened the past 3 years, as well has a handful of years in my childhood. The most recent years, it’s happened every spring, always follows a sickness, and no doctor or treatment brings me any relief. (Last year was tested for asthma, allergies, reflux and put on medication for all as well as prednisone, none provided any relief.) The strange things about my case are as follows: I don’t cough at night because I live alone and tend to not talk at night. Talking triggers coughing, making work a nightmare, and laughing makes it that much worse. I often get a weird tickle in my throat too (like a mosquito suddenly flies into my throat) that causes coughing and choking until I can’t breathe and have tears running down my face. (Luckily this is infrequent, but also happens occasionally throughout the rest of the year when the cough isn’t continually present where I have to confess to anyone around me that I “choked on air”.) I have no other symptoms other than a horrible nonstop cough that persists all day, gets worse the more I talk, and seems to go away on it’s own after 10-14 weeks.

    My question here is: Is this unusual and what does it mean? Every winter now, I am living in constant fear of getting sick knowing it will turn into this cough. Last year I saw my primary 3 times, an allergist 2 times, and an ENT and was so frustrated by then that I couldn’t bring myself to see a pulmonologist (I had asked my primary for amitriptyline and she would not prescribe it.) By early July, my cough finally subsided and I’ve been fine since then–now waiting cautiously knowing the cough will return soon.

    Have you ever treated anyone who’s neurogenic cough has acted in this way and is the treatment the same?

  17. Hi there

    I had a bad cold with a long cough that lasted a lengthly time. Cough healed but I know have burning throat, post nasal drip, excess mucous and swallowing to clear. I feel like I’m fighting phenamonia have developed all sorts of Gastro problems and heavy chest/pain feeling overnight. I have done all test and clear. I have always been fit eat good and never had a history of sinus or allergy problems. Do you think Amytriptiline would help me?

  18. Hi there

    I had a bad cold with a long cough that lasted a lengthly time. Cough healed but I know have burning throat, post nasal drip, excess mucous and swallowing to clear. I feel like I’m fighting phenamonia have developed all sorts of Gastro problems and heavy chest/pain feeling overnight. I have done all test and clear. I have always been fit eat good and never had a history of sinus or allergy problems. Do you think Amytriptiline would help me?

  19. Can you have this condition with no cough? I woke up burning from mouth to stomach even my ears burn ! This has been going on for over a year all day every day. Have last 29 percent of my body weight and was already small and am extremely fatigued . Have have many test and come up normal. My last GI suggested it could be a nerve issue but I don’t know how it could affect all these things.i also had a lot of belching in the beginning and still suffer nausea. Have you ever seen a pateint like me? Does it sound like it could be nerve damage? Desperately looking for a solution .

  20. Wow. I think I may have just discovered the reason for both my oversensitive gag reflex and the violent coughing fits that cause me to throw up and lose control of my bladder, often at the same time.

    I have a couple of questions.

    1. Would I still be a candidate for this diagnosis if my symptoms are not chronic, but are more occasional and usually triggered by something (ie, brushing my teeth, having dental work done or dealing with a cold with a lot of drainage)? Would treatment be different if symptoms were not chronic?

    2. Have you encountered anyone who becomes symptomatic at the mere thought of the trigger? For instance, there have been times when I have come close to triggering my gag reflex when brushing my teeth, but have been able to stop myself from vomiting by standing up straight, tilting my head back and taking slow and deep breaths. Once I feel the threat of vomiting has passed, and I try to resume brushing my teeth, I replay what just happened in my mind, and end up vomiting anyway.

    3. Have you noticed any connection between restless leg syndrome and this condition? I suffer from restless legs too, and your articles make me wonder if there is any comorbidity, given that both are neurologic conditions.

    I look forward to your insight on these questions. Thank you.

  21. To Brenda:

    Have your ever been evaluated for Postural Orthostatic Tachycardia Syndrome (POTS)? My daughter has this autonomic dysfunction, and many of your symptoms sound familiar. You might want to check out that possibility.

    Best wishes!

  22. I have seen Sensory Neuropathic Cough compared to post-herpetic neuralgia, but is it possible that it could be a sub-specimen of it? About 7 years ago, I had a shingles infection in my ear. By the time I was diagnosed, facial paralysis from Ramsay Hunt Syndrome had developed. I eventually regained 85 % or so of the movement of that side of my face, but in the past few years, I’ve found that after I get a cold, I invariably end up with a chronic cough that can last 3 months or more. And it almost always appears to be environmentally triggered. Eating, a change in temperature (or even going from inside to outside). Smells. Any of these would set off that tickling feeling that would then lead coughing and often then trigger my gag reflex, resulting in either dry heaves or epic vomiting sessions.

    When this happens, I try to treat with allergy medications and PPIs (I’m overweight and sometimes have Gerd). Some doctors have prescribed steroids which can mitigate the problem somewhat. But I’m never sure what makes it go away other than time. I have no doubt that post-nasal drip or GERD may contribute, but it still feels that I’m just uncommonly sensitive. I know the shingles did other funky things to my nervous system. My salivary glands appear to activate my the nerves to my tear ducts so that I have tears when I eat something savory. Which is a phenomena I’ve read about with others who developed Ramsay Hunt Experience.

    So if someone is still monitoring this blog, does this seem a plausible hypothesis, and is there anyone in the Washington DC area familiar with treating Sensory Neuropathic Cough?

    • Your hypothesis is perfectly plausible, though of course I am speculating without having met or examined you. So my comments are for what they are worth and only to help you work with your personal physician. There is a branch of the vagus nerve called Arnold’s nerve, and it explains why some people cough when they clean their ears with a q-tip. You should try to find a person who is skilled and experienced with treating SNC. Call nearby ENT groups of some size and ask to speak to the triage nurse. Ask “Does anyone in your group treat numbers of patients with sensory neuropathic cough?” If “no” or “I’ve never heard of that,” or even “crickets,” call the next group. I suspect someone at a university ENT group will have experience…

  23. We live in Bethlehem Pa. My wife has had a chronic cough for years. She has been to numerous doctors that say they are familiar with sensory neuropathic cough, but once we get to the appointment, they say they don’t believe that is what she has. They send her for tests,and throw up their hands once the tests are negative. I haven’t been able to find a doctor near us. Where can I look to find a list of specialists that treat SNC. Thank You

    • Sorry to hear about your wife’s problem. Dr. Bastian does do video chats with people like you as long as you understand it is to refine a potential strategy you could pursue with your personal physician—even your primary care doctor. He has also replied briefly as follows:

      “The best idea is to call to the ENT group you are considering and ask to speak to the triage nurse. Ask the question: ‘Does any of your doctors treat numbers of patients with sensory neuropathic cough?’ If the response is a pause, or “no” or a stumbling answer, call the next group.”

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