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Refractory Chronic Cough: Recognizing the Burden and Improving Care

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Released: September 15, 2026

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Refractory chronic cough (RCC) is a prevalent condition, but its life-disrupting consequences go unrecognized, and RCC-related burdens experienced by patients are often compounded by delayed diagnosis and treatment. Fortunately, increased understanding of RCC, including its underlying neurogenic pathophysiology, can improve care for patients with this condition. Read this commentary for key patient perspectives and expert insights on RCC challenges, diagnosis, and management. 

Peter Dicpinigaitis
Peter Dicpinigaitis, MD
Robert, Patient
Robert, Patient
RCC Burden and Better Care


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Burdens Posed by Refractory Chronic Cough
Before getting into the diagnosis and management of refractory chronic cough (RCC), healthcare professionals (HCPs) should understand the challenges patients with RCC face. “I've been doing technology support since 1988, which requires a lot of phone time, a lot of talking to people. The cough makes it difficult to be efficient with the customers, to talk to them. And it's unfortunate to have to hold the phone away and cough,” Robert, a patient with RCC, says. “The customers, I'm sure, get disturbed by that. I am, maybe even more than the customers.  And it's difficult when you're going out with friends to not talk because you don't want to start coughing in the middle of them. So it affects you a lot.”

Unfortunately, laypeople and HCPs alike underestimate the tremendous toll RCC can have on a person’s quality of life. Furthermore, spouses, family, friends, and coworkers comprise expanded networks of concerned sufferers around patients with RCC. The hypersensitivity of the cough reflex that underlies RCC causes patients to cough from triggers that do not induce cough in otherwise healthy people. Those common triggers include changes in air temperature; strong smells, such as perfume, cologne, and household detergents; and mechanical stimuli like laughing, singing, and talking. As noted, RCC can be extremely disruptive to a person whose occupation involves personal or telephone-based interactions with clients and/or working in cold weather or environments that contain cough-inducing triggers.

Social isolation is another unfortunate result of RCC. Many patients are reluctant to go out in public, eat at restaurants, visit the theater, or attend church due to the fear of having a severe coughing bout that brings attention to themselves. It is not surprising that multiple studies have demonstrated increased incidence of anxiety and depression among patients with RCC.

RCC Diagnosis
The diagnostic journey of a patient with RCC can be long, frustrating, and often unfruitful. We know that most patients with chronic cough, defined as cough of greater than 8 weeks duration, will respond to appropriate therapy that targets its 3 main causes, those being upper airway cough syndrome, previously known as postnasal drip syndrome; asthma and nonasthmatic eosinophilic bronchitis; and gastroesophageal reflux disease (GERD). Unfortunately, a thorough and complete evaluation of underlying causes of cough is often not performed, or can take many months or years, involving visits to multiple HCPs in primary care and specialties. Patients may churn through the healthcare system seeking further evaluation from specialists when the underlying cause of their chronic cough is not identified. This can then lead to repetition of diagnostic assessments, such as CT scans of the chest and sinuses, upper gastrointestinal endoscopies, pulmonary function and bronchoprovocation studies, and unnecessarily long empiric trials of medications (eg, inhaled steroids, proton pump inhibitors).

“I was trying to find what was causing the problem back in the 1990s. I went through multiple different doctors, and they each did their own tests. It wasn't until the early 2000s that a specialist said that this is a neurogenic cough. He also went through all of the testing,” says Robert. “Then in October 2024, I decided to go back and see if there was a technology change that might be able to help me, and the doctor had me go through the testing again. I think the appointments covered about a month and a half. They did an x-ray, allergy tests—both blood tests and the spots on your back, where they put about 100 things to see if you're allergic to any of them—and pulmonology tests and came to the result again that it was a neurogenic cough.”

As Robert’s story highlights, a contributor to the repetitive, cyclical evaluation that patients with chronic cough often endure is the lack of a timely diagnosis of RCC, which is defined as a chronic cough that has not responded to proper empiric therapy aimed at the known underlying causes. Without an informed HCP establishing a diagnosis, patients can get stuck in a cycle of ongoing diagnostic studies and unsuccessful empiric drug trials. Arriving at a correct diagnosis of RCC is vitally important because it establishes that the patient has a distinct medical condition driven by vagal nerve hypersensitivity and leading to an enhanced cough reflex sensitivity. Finally receiving a diagnosis can be very comforting and validating to a patient, as it establishes that they have a specific medical condition.

RCC Treatment Options
Reflecting on his RCC journey, Robert notes, “In the early 2000s, I was diagnosed with neurogenic cough, but at that time, they said they couldn't do anything about it. I decided in October of 2024 to see if technology has changed, and this time the specialist I saw said there was a treatment available.”

Once a correct diagnosis of RCC is established, additional efforts at identifying other causes of chronic cough can cease, and the focus shifts to addressing the underlying etiology of RCC, which is vagal nerve hypersensitivity causing enhanced cough reflex sensitivity. Unfortunately, at the time of this commentary, there are no FDA-approved therapies indicated for RCC. In Japan and Europe, gefapixant, a selective P2X3 receptor antagonist, is the first therapy approved to treat unexplained RCC. However, HCPs in the US and many other countries are limited to off-label use of select therapies to treat RCC.

Opioids such as codeine and morphine are often considered unattractive options by physicians and patients alike, especially if long-term therapy is anticipated. However, there is a randomized controlled trial that demonstrated efficacy and tolerability with low-dose, slow-release morphine vs placebo in RCC. Most HCPs initiate empiric therapy with neuromodulators like amitriptyline and gabapentin (or pregabalin). Unfortunately, these therapies are generally ineffective or not tolerated well at the dose required to suppress cough due to sedation or other adverse effects. The past decade has increased awareness of the important role of speech-language pathologists (SLPs) on RCC management teams. Randomized clinical trials have demonstrated that speech-language pathology regimens incorporating patient education, breathing exercises, and vocal hygiene strategies can have a positive effect on RCC. Finally, HCPs should refer patients with RCC to any ongoing clinical trials in their area.

Your Thoughts
How often do you initiate a neuromodulator like amitriptyline or gabapentin as a first-line therapy for patients with RCC? You can get involved in the conversation by answering the poll question and posting a comment below.

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How often do you initiate a neuromodulator like amitriptyline or gabapentin as a first-line therapy for patients with RCC?

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