Disclaimer: This article is provided for informational purposes only and does not constitute medical advice. Clinicians must exercise independent professional judgement and consult relevant guidelines when making patient care decisions.
Abstract
Neurogenic cough is a persistent, unexplained cough increasingly recognised as part of cough hypersensitivity syndrome. Amitriptyline, a tricyclic antidepressant, is sometimes prescribed off-label at low doses and can provide short-term relief. However, cumulative exposure carries risks including cognitive impairment and dementia. This review summarises the pathophysiology of neurogenic cough, the rationale and limitations of amitriptyline, guidance on tapering, and a structured six-session Behavioural Cough Suppression Therapy (BCST) programme supported by clinical trials and guidelines.
Introduction
Chronic cough, defined as lasting longer than eight weeks, is often multifactorial. In cases without asthma, reflux, or infection, the diagnosis of neurogenic cough (or refractory/unexplained chronic cough) is considered. It is conceptualised as cough hypersensitivity syndrome, where airway nerves over-respond to otherwise minor stimuli such as perfumes, cold air, or talking. The result is an uncontrollable urge-to-cough with substantial quality-of-life burden (Morice et al., 2020).
Amitriptyline for Neurogenic Cough
Mechanism of Action
At low doses (e.g., 10 mg nightly), amitriptyline reduces nerve excitability and central cough reflex sensitivity. It also provides sedative effects that may reduce nocturnal coughing (Visca et al., 2020).
Short-Term Benefits
Patients often report reduced cough severity and improved sleep within weeks. Small observational series and clinical experience support this, though high-quality RCTs are lacking (Visca et al., 2020).
Risks of Long-Term Amitriptyline Use
Anticholinergic Burden
Amitriptyline is a strong anticholinergic. Chronic blockade of muscarinic acetylcholine receptors impairs memory and learning.
Dementia Risk Evidence
- Gray et al. (2015): Long-term use of strong anticholinergics was associated with a 54% increased risk of dementia in a prospective cohort.
- Coupland et al. (2019): A nested case–control study showed a nearly 50% increased risk of dementia in those exposed to tricyclic antidepressants and bladder antimuscarinics.
Biological Mechanisms
- Exacerbation of existing cholinergic deficits.
- Promotion of neuroinflammation and oxidative stress.
- Acceleration of amyloid-β and tau protein deposition.
- Potential changes in cerebral blood flow.
Tapering Protocol for Amitriptyline
Abrupt discontinuation can cause insomnia, irritability, headache, and rebound cough. Safe tapering is essential:
- Step 1: Reduce from 10 mg to 5 mg nightly for 1–2 weeks.
- Step 2: If tolerated, discontinue. If symptoms recur, extend 5 mg step for 2–4 weeks.
Supportive measures: sleep hygiene, mindfulness, hydration, and relaxation breathing.
Six-Session BCST Programme
Evidence base: Vertigan et al. (2006); Chamberlain Mitchell et al. (2017); Morice et al. (2020); Yi et al. (2024).
Outcome tools: VAS cough severity (0–100 points), UTC (0–100 points), LCQ (3–21, MCID = 1.3) (Raj et al., 2009; Nguyen et al., 2021).
Session 1 — Education
Goals: Explain cough hypersensitivity; establish baseline (VAS, UTC, LCQ); identify triggers; teach one suppression micro-skill.
In-session: Psychoeducation; baseline scoring; trigger ranking; teach “micro-set” (nasal inhale → swallow → 2–3 s hold → slow exhale, sip of water optional).
Homework: Daily VAS/UTC logs; trigger diary; practise micro-set 3× daily and at first urge.
Example Daily Log
| Date | VAS | UTC | Trigger | Notes |
|---|---|---|---|---|
| 1 Sept | 72 | 78 | Cold air | Micro-set reduced urge in 30 s |
Session 2 — Trigger Management
Goals: Develop personalised coping strategies for high-risk triggers.
In-session: Review logs; practise substitution behaviours (nasal breathing, sipping water, silent swallow).
Homework: Use strategies during exposures; complete trigger logs.
Example Trigger Log
| Date | Trigger | Strategy | Urge | Outcome |
|---|---|---|---|---|
| 3 Sept | Perfume aisle | Nasal breathing + sip | 65 | No cough, urge subsided |
Session 3 — Automaticity
Goals: Break habitual cough loop; introduce IF–THEN action plans.
In-session: Rehearse suppression techniques under mild provocation (controlled exposure).
Homework: Apply IF–THEN plans (e.g., “If I feel an urge in conversation, then I swallow and breathe nasally”).
Session 4 — Vocal Hygiene
Goals: Reduce laryngeal irritation; discourage throat clearing.
In-session: Hydration counselling; introduce “silent cough” or hard swallow as clearing substitutes.
Homework: Record daily fluid intake and throat-clearing events.
Session 5 — Troubleshooting
Goals: Identify barriers; manage relapses; reinforce strategies.
In-session: Review adherence; problem-solve non-responding triggers.
Homework: Maintain logs; add micro-practice sessions if adherence < 80%.
Session 6 — Consolidation
Goals: Review progress; relapse prevention; plan for self-management.
In-session: Compare baseline and current VAS, UTC, LCQ. Define thresholds for re-contact (VAS increase ≥ 20 points or LCQ drop ≥ 1.3).
Homework: Weekly monitoring logs for 4–8 weeks.
Follow-Up Monitoring
- Reassess at 4–8 weeks post-programme, then every 8–12 weeks if needed.
- Success = LCQ ↑ ≥ 1.3, VAS ↓ ≥ 30 points, or sustained UTC reduction.
Conclusion
Amitriptyline can reduce cough sensitivity in the short term but carries significant risks with long-term use, including dementia. A structured taper combined with a six-session BCST programme provides sustainable cough control and aligns with guideline recommendations for non-pharmacological management.
References
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