Diagnostic and Management Approach to Reflux-Related Cough

Chronic cough, defined as cough persisting longer than 8 weeks, affects approximately 10% of the global population and significantly impairs quality of life. Gastroesophageal reflux disease is a recognized cause of chronic cough, yet the relationship remains complex and poorly understood. Up to 75% of patients with reflux-related cough lack classic gastroesophageal symptoms such as heartburn or regurgitation, making diagnosis particularly challenging. Although direct tissue irritation by refluxate has been proposed as a primary mechanism, evidence also supports a vagally mediated esophageal- tracheobronchial reflex. Cough hypersensitivity is also recognized as an important mechanism, amplifying responses to reflux and contributing to persistent symptoms despite reflux-directed therapy. Diagnostic evaluation requires a structured approach integrating clinical assessment, empiric treatment trials, and objective testing including ambulatory reflux monitoring. Upper endoscopy may reveal reflux complications, but most patients with reflux-related cough have normal endoscopic findings. Management involves a stepwise approach beginning with lifestyle modifications and proton pump inhibitor therapy, with neuromodulators and behavioral interventions reserved for refractory cases. Surgical intervention may benefit carefully selected patients but requires shared decision-making regarding risks and benefits. Development of more accurate diagnostic tools and unified clinical guidelines will be critical for advancing the management of this difficult-to-treat condition. This article reviews reflux-related cough, including its diagnostic evaluation and management strategies.