Intended for healthcare professionals

Clinical Review State of the Art Review

Management of chronic refractory cough

BMJ 2015; 351 doi: (Published 14 December 2015) Cite this as: BMJ 2015;351:h5590
  1. Peter G Gibson, director1,
  2. Anne E Vertigan, speech pathologist2
  1. 1Centre for Asthma and Respiratory Disease, University of Newcastle; Department of Respiratory and Sleep Medicine, John Hunter Hospital; Hunter Medical Research Institute, Newcastle, NSW, 2010, Australia
  2. 2Centre for Asthma and Respiratory Disease, University of Newcastle; Speech Pathology Department, John Hunter Hospital; Hunter Region Mail Centre, Hunter Medical Research Institute
  1. Correspondence to: P Gibson peter.gibson{at}


Chronic refractory cough (CRC) is defined as a cough that persists despite guideline based treatment. It is seen in 20-46% of patients presenting to specialist cough clinics and it has a substantial impact on quality of life and healthcare utilization. Several terms have been used to describe this condition, including the recently introduced term cough hypersensitivity syndrome. Key symptoms include a dry irritated cough localized around the laryngeal region. Symptoms are not restricted to cough and can include globus, dyspnea, and dysphonia. Chronic refractory cough has factors in common with laryngeal hypersensitivity syndromes and chronic pain syndromes, and these similarities help to shed light on the pathophysiology of the condition. Its pathophysiology is complex and includes cough reflex sensitivity, central sensitization, peripheral sensitization, and paradoxical vocal fold movement. Chronic refractory cough often occurs after a viral infection. The diagnosis is made once the main diseases that cause chronic cough have been excluded (or treated) and cough remains refractory to medical treatment. Several treatments have been developed over the past decade. These include speech pathology interventions using techniques adapted from the treatment of hyperfunctional voice disorders, as well as the use of centrally acting neuromodulators such as gabapentin and pregabalin. Potential new treatments in development also show promise.


  • Contributors: PGG and AEV devised the outline for the paper. PGG selected research articles for review and completed the initial draft of the assessment section. AEV completed the initial draft. Both authors revised the final draft. PGG is guarantor.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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