You May Not Have to Live with that Chronic Cough

Introduction

Imagine . . . coughing for 10 years. That’s what has happened to “Susan.”

When an attack hits during a phone call, friends have learned to say, “Uh-oh, well, call me back when your cough is over.” If a bad spell happens in public, she feels humiliated when all eyes turn her way. People draw back, afraid of catching her “illness.” At church, she sits on the aisle, by the exit. “I haven’t made it through an entire service in these past 10 years,” she says. “And the cough awakens me at least once a night, and sometimes twice. I’m exhausted and desperate.”

This is not your typical cough.

Susan says, “Not only does the cough happen often for no reason at all, but there are things I can’t do without increasing the likelihood of coughing: talking, breathing in cold air, singing, laughing, and even swallowing. If I do those things, I am more likely to develop a sudden tickle or a feeling like a little patch of sandpaper in my throat, and I begin to cough.”

A Serious Cough

People with Susan’s problem may cough anywhere from a few times to hundreds of times per day. When coughs number in the hundreds, most of them typically last a few seconds. And sometimes people just clear their throats in response to the tickle or itch. An even bigger problem is when some of the episodes are violent and protracted, even minutes long.

During one of those attacks, the person may cough until they feel “inside out.” The face may turn red, eyes tear, and nose runs. Some lose urine due to the aggressiveness of the cough. Towards the end of a major attack like this, they may gag and nearly, or actually, throw up.

A few cough so hard that they break a rib.

In cases like Susan’s, physicians typically seek the usual suspects: cough-variant asthma, acid reflux, postnasal drip, allergy, and certain blood pressure medications called ACE-inhibitors. Even when tests for these conditions are negative, treatment for these diagnoses may still be tried, but with little if any benefit. Enter, at long last, a new diagnosis. Its name: Sensory neuropathic cough—SNC for short.

Establishing a Diagnosis…

Discovered and codified by Dr. Robert Bastian of Bastian Voice Institute in Downers Grove, SNC is essentially a disorder of sensation. An analogy might be neuralgia—the burning sensation lasting months or even permanently, after an outbreak of shingles. Or the phantom pain in a leg that was amputated years before. But in this case, the phantom sensation is that tickling or dry throat sensation that leads irresistibly to coughing.

Humans do need to cough sometimes, of course. For example, if one has pneumonia or has inhaled a gnat at a picnic, coughing is good and helps to clear the lungs. By contrast, with SNC, the aberrant sensation and associated cough are bad, and coughing here is the problem, not the solution to a problem.

…Finding a Cure

Medications for neuropathic pain or neuralgia are often effective for SNC. There is a long list of options, but the initial two are amitriptyline or desipramine and gabapentin. The first two were originally used for depression, but now more commonly and in lower doses for atypical pain, neuralgia, and prevention of migraine. The third was first used as a seizure medication to “calm down” the “electrical storms” in the brain that trigger seizures. Now gabapentin is used most often for neuropathic pain and neuralgias.

Farther down the list for persons whose coughing does not respond to amitriptyline or gabapentin are medications like duloxetine, venlafaxine, citalopram, topical capsaicin spray, mirtazapine, and injections of a combination of triamcinolone (a long-acting local steroid) and bupivacaine (a long-acting local anesthetic).

A Life Restored

Amitriptyline didn’t work for Susan. But upon starting gabapentin, she couldn’t believe the difference. Says her husband, “Now we always get through church, and are virtually never awakened at night with her coughing.” Susan notes that she still coughs or clears her throat a bit from time to time, and it “kicks up” for a few weeks after each upper respiratory infection. Yet, she rarely if ever coughs in the wracking way she had before. “I have my life back,” she says.