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Laryngopedia

To educate about voice, swallowing, airway, coughing, and other head and neck disorders

A Journal of Observational Laryngology

Clinical observations, anecdotes, and insights which other clinicians may want to consider and test with further research.

About the Journal

The Use of Capsaicin for Sensory Neuropathic Cough

By Robert W. Bastian, MD

In recent years, a neurogenic form of chronic cough has been described in the literature, referred to variously as “sensory neuropathy presenting as chronic cough” 1 , “sensory neuropathic cough” 2 , 3 , “laryngeal sensory neuropathy” 4 , or simply “refractory chronic cough” 5 . It has been shown that sensory neuropathic cough (SNC) can be treated with certain neuralgia medications 1,4,5, 6 , 7 , 8 . What has not yet been described, however, is the use of capsaicin spray as a possible treatment for SNC patients—an approach that may seem counter-intuitive, given that capsaicin is known in the pulmonary medicine literature as a means for provoking coughing for diagnostic or research reasons.

The Genesis of the Idea
In 2005, a desperate patient traveled a considerable distance to consult regarding her terrible intractable cough. She described the typical abrupt, intense tickle at the start of each cough; she also noted the trigger phenomena previously described as a part of SNC 2 . For many years, she had experienced dozens of coughing episodes per day. Many of her episodes lasted a minute or more and, due to the violence of her attacks, led to public humiliation; she suffered from retching, occasional vomiting, and frequent stress incontinence. Based upon this history alone, as well as a negative examination, the criteria for a diagnosis of SNC were met. In addition, she had been previously treated for years for the “usual suspects”—cough-variant asthma, acid reflux, allergy, and post-nasal drip; none of the many medications she had tried for these conditions had helped at all.

Unfortunately, this patient’s case was unusually refractory to our list of SNC medications—in this case, amitriptyline, gabapentin, and oxcarbazepine (later on, she also tried pregabalin). After we managed our customary protocol for each of these medicines by phone across the next few months, we learned together that her cough could be diminished (by as much as 40%), but only if she took high doses of medication, to the point of experiencing unacceptable side effects.

In casting about for additional treatment options, we focused on the fact that her particular stereotyped cough-inducing sensory disturbance was an irresistible tickle at the level of the thyroid cartilage on the left side.

To continue the search for a solution, it seemed logical to infiltrate lidocaine with epinephrine into the area of the left superior laryngeal nerve. Such a nerve block should linger for at least an hour, and since her coughing occurred at least a few times per hour, it seemed that the assessment of benefit, if any, would be easy. After the first injection, the patient reported that she did not cough at all for two days. She was thrilled. Two additional injections were planned in order to validate the benefit of the first injection. Unfortunately, the second injection did not help.

In response to my many questions trying to make sense of the difference between the two injections, the patient commented that the first injection had left her visibly bruised, sore, and somewhat swollen. The second (ineffective) injection did not cause any of these side effects. She in fact requested a third injection that would intentionally make her bruised and sore, as the first one had.

This patient’s story triggered a rapid-fire series of thought experiments: the use of a laser burn as a kind of long-lasting counter-irritant, or the use of extremely powerful mint, or, the use of capsaicin. At that time, capsaicin had been used in topical skin creams to treat various kinds of pain 9 , and also as an intranasal spray for headaches 10 .

This patient initially used capsaicin spray obtained for her from a compounding pharmacy, prepared at 0.03% strength. Without any available guidelines, and wanting an answer quickly, I suggested that she use the capsaicin as often as 10 times per day. This gave her heartburn (predictably) and markedly increased her tolerance of hot food. Later, she stepped down to using the capsaicin four times per day. Unfortunately, the capsaicin only helped her cough somewhat. She used it for some time, but then dropped it.

From 2005 to the present, we have tried capsaicin spray in well over a hundred patients. It is typically the fourth approach we try, and only after failure of three different neuralgia medications such as the medications mentioned above, as well as citalopram and desipramine. A small percentage of patients who try capsaicin have experienced major relief. This is why we continue to suggest it as a fourth option.

Possible Kinds of Relief
There appear to be at least three different ways in which capsaicin might relieve an SNC patient’s coughing symptoms. When a patient is supplied his or her first bottle of the spray from us, we explain that we want them to test for the following three potential benefits:

  1. May reduce the frequency and severity of coughing attacks. At the outset of our use of capsaicin, our theory was that, if this benefit were to occur, it would be as a counter-irritant, as suggested by the patient anecdote above. Subsequently, we thought that this benefit might occur because of desensitization, via gradual depletion of substance P, a neurotransmitter found in the mucosa 11 . However, more recent information suggests that capsaicin desensitizes primarily through a process called “defunctionalization” of thermal, mechanical, chemical, and other sensory nerve endings 12 . To test capsaicin’s potential to “defunctionalize” nociceptors, we suggest a trial of at least two weeks, using the spray four times per day. The person is told that use of capsaicin can trigger a bout of coughing, much as asthma inhalers that were prescribed by prior physicians often do, and that they must simply carry on with the capsaicin trial for a minimum of two weeks, even in the face of this obnoxious impediment. A number of patients have obtained relief in this way.
  2. May act as a counter-irritant to abort or truncate bad attacks. This idea came up because one early patient commented that she was pleased with capsaicin even though her cough frequency was unchanged. She explained that she could tell when an attack was going to be unusually severe and prolonged, often by the “urgency” of the preceding tickle. If she could spray her throat immediately after such an urgent sensation, the attack was shortened. She said that, instead of a typical two-minute duration, the coughing spell might be over in 20 seconds. It is of course impossible to conclude anything from this anecdote, but for what it is worth, other patients have said this works for them, too.
  3. May serve as a “cough scheduler” by providing temporary relief from coughing after a capsaicin-induced attack. This idea was contributed by a patient who said that, though capsaicin did not help his coughing problem in either of the two ways mentioned above, he was happy with a different benefit he had discovered:if he used the capsaicin to induce an attack of coughing, he would then enjoy an unusually extended period of time without cough. For example, if he were going to see a play, he would spray his throat just before the play started, have a vigorous attack of coughing as a result, but then be able to get to the intermission without coughing. During the intermission, he would again spray his throat (in the bathroom or outside the theater); a second major episode of coughing would occur, but then he could get through the second half of the performance also without coughing.

How to Apply the Capsaicin
These are the instructions we give our patients for applying the capsaicin spray:

  1. Stand in front of your bathroom mirror, open your mouth widely, and try to look as far back into your mouth as possible.
  2. Depress your tongue so that, if possible, you see the back wall of your throat, and not just your tongue or palate.
  3. Take a deep breath, hold it in, and aim the capsaicin spray straight back, attempting to hit the back wall of the throat, and not the front of the mouth. Immediately after spraying, exhale and swallow. You will feel the “heat” of the capsaicin for at least 5 minutes.
  4. Do not eat or drink anything for a minimum of 10 minutes before or after using the spray. This is so that ingested substances do not inadvertently “neutralize” the capsaicin (particularly milk, citrus, salt, etc.).
  5. Repeat this routine four times a day for a minimum of two weeks (three is better), before deciding whether or not capsaicin is a worthwhile option.

Going Forward
Our sense is that perhaps no more than one in ten patients who try capsaicin after “failing” the usual neuralgia medications (such as amitriptyline, gabapentin, and several others) end up finding capsaicin to be beneficial, in one or more of the three ways described above. We hope to provide a more formal report of our experience with capsaicin in the near future.

Bastian ZJ, Bastian RW. (2015) The use of neuralgia medications to treat sensory neuropathic cough: our experience in a retrospective cohort of thirty-two patients. PeerJ 3:e816 https://dx.doi.org/10.7717/peerj.816

  1. Lee B, Woo P. Chronic cough as a sign of laryngeal sensory neuropathy: diagnosis and treatment.Ann Otol Rhinol Laryngol. 2005; 114: 253-257. [↩]
  2. Bastian RW, Vaidya AM, Delsupehe KG. Sensory neuropathic cough: a common and treatable cause of chronic cough.Otolaryngol Head and Neck Surg. 2006; 135(1): 17-21. [↩]
  3. Gibson PG, Ryan NM. Cough pharmacotherapy: Current and future status.Expert Opin Pharmacother. 2011; 12(11): 1745-1755. [↩]
  4. Halum SL, Sycamore DL, McRae BR. A new treatment option for laryngeal sensory neuropathy.Laryngoscope. 2009; 119:1844-1847. [↩]
  5. Ryan NM, Birring SS, Gibson PG. Gabapentin for refractory chronic cough: a randomized, double-blind, placebo-controlled trial.Lancet. 2012; 380(9853): 1583-9. [↩]
  6. Jeyakumar A, Brickman TM, Haben M. Effectiveness of amitriptyline versus cough suppressants in the treatment of chronic cough resulting from postviral vagal neuropathy.Laryngoscope. 2006; 116: 2108-2112. [↩]
  7. Van de Kerkhove C, Goeminne PC, Van Bleyenbergh P, Dupont LJ. A cohort description and analysis of the effect of gabapentin on idiopathic cough.Cough. 2012; 8(9). [↩]
  8. Norris BK, Schweinfurth JM. Management of recurrent laryngeal sensory neuropathic symptoms.Ann Otol Rhinol Laryngol. 2010; 119(3): 188-191. [↩]
  9. Mason L, Moore A, Derry S, Edwards JE, McQuay HJ. Systematic review of topical capsaicin for the treatment of chronic pain.Br Med J. 2004; 328:991–997. [↩]
  10. Rapoport AM, Bigal ME, Tepper SJ, Sheftell FD. Intranasal medications for the treatment of migraine and cluster headache.CNS Drugs. 2004; 18(10): 671-85. [↩]
  11. Burks TF, Buck SH, Miller MS. Mechanisms of depletion of substance P by capsaicin.Fed Proc. 1985; 44(9):2531-4. [↩]
  12. Anand P, Bley K. Topical capsaicin for pain management: therapeutic potential and mechanisms of action of the new high-concentration capsaicin 8% patch.Br J Anaesth. 2011; 107(4):490-502. [↩]

50 thoughts on “ The Use of Capsaicin for Sensory Neuropathic Cough ”

I have been using Capsaicin spray to manage chronic non allergic rhinitis and found that benefit lasts approximately 9 months. I have been using it in patients with chronic refractory cough, most of whom are taking codeine, amitrypiline and / or gabapentin or analogues. The difference from your study is athta all patients get speech therapy modification of laryngeal behaviour and alos3 units of botox to each thyroartyenoid muscle prior to commencement of weekly capsaicin spray in my rooms for 3 weeks. It is critical that all three treatments are used. The botox causes a ‘huff’ cough rather than explosive blast reducing recurrent trauma. the Speech pathology input reduces laryngeal mucous clearing mechanisms and improved laryngeal humidification / moisture. The capsaicin is used to reduce the cough sensitivity threshold temporarily whilst the other management strategies are at work. We use the Newcastle Laryngeal Hypersensitivity Questionnaire (Vertigan et al) to monitor response to care. Although treatment may require repetition at 4-6 monthly intervals, requirement to remain on medication is ceased and control of cough is improved allowing normality of life style.

Thanks so much for your input. Years ago, I used to send cough patients to the speech pathologist for what we called “sword swallowing school.” The idea was that if a sword swallower has to learn to tolerate the sensations of that act, perhaps cough patients could learn to tolerate or distract from a powerful urge to cough. It seemed to help only a small percentage, and not at all the true sensory neuropathic cough patients. So we no longer do this routinely. As for Botox, we have also tried that with variable results, and of course there is a penalty as voice is weakened for a time in order to diminish the percussiveness of cough. I do, however, very much like the intensity of your attack on this problem, a problem which can destroy quality of life for so many. And your comments have made me do some rethinking about other options.

Hello – I have read your article with interest. I live in the UK, am 61 and have suffered with a chronic cough as described above for the past 7 years. I have tried a range of remedies from amitriptyline to nasal sprays to antihistamine etc all to no avail. I note that a glass of red wine can help subdue my symptoms but as that is not a good route to follow I have considered what else might pacify the awful trigger that sets me coughing! I have often noticed that spiced food can also have a calming effect on my cough and have commented that if only I could apply a patch impregnated with chilli to the inside of my throat that would do the job. That thought has led me to your article today.
I sense there is a correlation between my cough and heart palpitations that I experience too and wonder if the application of capsaicin might cause adverse symptoms in that respect.
I’m not sure I am brave enough to spray capsaicin down my throat in the way you describe but will continue to follow your website for future developments.
I’m afraid I have little to add by way of a contribution to this topic but am reassured to read it as my General Practitioner and Ear Nose and Throat Consultant have just seemed rather baffled by me and disinclined to contemplate the neuropathic aspect of it for me. I feel much less isolated for reading your article. Thank you

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The frustration that so many with sensory neuropathic cough experience is well-represented in your comments. Many physicians who so want to help are also frustrated when all their efforts – usually directed at what we call “the usual suspects” of allergy, asthma, and acid reflux – are useless. Depending on your motivation and the details of your case, your physician(s) might be willing to try you on gabapentin, according to sensory neuropathic cough protocols you can find for this medication. It would be a shame for you to learn only after years of additional coughing that this medication helps! Consider reading a more recent article, by the way, on “medical jadedness” that can prevent or delay finding solutions.

Thank you . I appreciate the suggestion to consider Gabapentin and will pursue that further . I’m wary of a remedy where the ‘trade off’ may be a general dulling of my senses on a daily basis and so have been cautious of that type of treatment. I read your ‘medical jadedness’ article with interest and can appreciate both sides of the scenarios referred to. My experience in the UK has been one of short consultations where the professionals, on the whole, are disinclined to engage in a dialogue of any depth with me and this has not been helpful. The first time I ever sought consideration that my cough may be something more than a virus the GP ‘s response was to say ‘You may cough for the rest of your life, how do you feel about that?’ , without quantifying his statement in any way -The first ENT consultation I had was founded on an assumption that I was worried that I had throat cancer – something wholly inaccurate and only came to light when I had sight of the consultant’s reply in my GP’s surgery!! It was eventually suggested that I had glossopharyngeal neuralgia & I was given a printed article to take away that detailed a painful condition which is not my experience so rather confused me!
My enlightenment regarding my own predicament has mainly come from trawling the internet and finding articles such as yours. Sadly there seems to be a ‘climate’ within the medical profession here that patients should not attempt to apply their intellect in medical territory and so useful dialogue is limited if the exchanges can only be at a very basic level & misunderstandings can prevail. I do appreciate that ‘ a little knowledge is a dangerous thing’ but I do believe that I could perhaps have been encouraged to be more involved!
I would be very interested to know if you have a counterpart in the UK. I have identified a ‘Cough Research Clinic’ in Hull but there doesn’t seem to be anything published about their work in recent times. Once again, thank you for your interesting articles, they certainly help .

I am very sorry to hear of the difficulty you have experienced in finding help for your cough. Intractable coughing that does not fit under any of the “usual suspect” causes of coughing (allergy, acid reflux, atypical asthma) can frustrate patience and doctors alike. I do think we are entering an era now of much increased awareness and understanding of neurogenic coughing. Of course I cannot say that that is what you are experiencing. That would be for your personal physician to consider. Still, if you match fairly accurately the scenario described for that condition, it could not hurt to ask your GP for a trial of amitriptyline. We use a dose escalation strategy, beginning with 10 mg, and increasing to as much as 80 mg before deciding (if no response) that that isn’t the solution. If it is not, then we proceed to gabapentin. For that medication, would begin with 300 mg at bedtime, and then after 3 days 300 mg twice a day; after another 3 days 300 mg 3 times a day, and then end with 300 mg 4 times a day, for a total of 1200 mg per day. If a person is unable to tolerate side effects, we can do the same strategy of escalation, but using 100 mg capsules. For what it is worth, it seems to me that 4 out of 5 people can tolerate this kind of dose level with an acceptable level of side effects in return for (potentially) great benefit.

I am very sympathetic with your desire to avoid medicines that might cause side effects. In fact a philosophy of as little use of medicine as possible is generally a good one. That said, persons with severe SNC are often desperate, and they may also experience major reduction of quality of life. For that reason, it would be useful to check out the above kinds of medicines, even if one knew in advance that he or she would be unwilling to stay on them permanently. Why not just answer the question: “Might this help me?”

As for a cough center in England, I am afraid I can’t help you with that. Just be forewarned that many cough research units might be expected to still be flogging those “usual suspects” described above. It can mean a great number of tests without much in the way of findings or much in the way of relief. That’s why I almost think it might be better to find a sympathetic GP to help you.

Thank you again for your very helpful information. I am hoping to retire shortly which will mean I am exposed to less ‘triggers’ eg a very poor physical environment, badly ventilated, dry atmosphere that prevails at work.
I think that will be the time when I take a decision regarding medication and I will particularly be enquiring about Gabapentiin as a possible solution. If I am not in the workplace I will be in a better position to deal with possible side effects such as drowsiness.
I will post feedback on any progress. Kind regards Sue

Hi I also live in the UK and like you feel that doctors are baffled by this cough. I’ve had the problem for over 10 years and to say it ruins my life is an understatement . Seen yet another GP and asked to be referred to a specialist but yet again told to try antibiotics and a nasal spray. My tone of voice is changing the cough now makes me feel like I’m going to choke and retch. I’ve been told to try not to cough, sip water any maybe it’s just a bad habit. What’s the point I give up .

I read this last night. Thank you!

I’ve had a chronic cough since 5/2010 after a nasty bout with bacterial pneumonia in the hospital. I was so sick, they put me in a coma for four days with a respirator, 3 weeks total in the hospital with heavy-duty antibiotics.

My voice never recovered, I have granulomas on my vocal chords and this cough. I had no idea what it was or what to do about it. I, like so many others, assumed it was reflux. I do think that’s part of it. I was a singer in a band and, just before I got sick, I experienced some voice cracking and loss of control which NEVER happened before. I think that was a clue that there was already some reflux damage on the chords. Maybe the granulomas were already forming.

The few times the cough has slowed in recent weeks, my voice gets noticeably better. I had a real gravelly voice when I got out of the hospital, no range, no power. I have more range since then and not so gravelly, just kinda whiskey, so something good is happening there. But after a day of coughing (I often cough till I gag), it’s wrecked again.

A few weeks ago, I read a book on chronic cough written by another doctor. She answered many questions, and made the upper respiratory/chronic cough connection for me. I fit the profile of someone with silent reflux. Then a friend, Reed Davis, led me to your site.

I’m so desperate, I drank a 1/4 tsp cayenne pepper mixed in water before bed and 2x so far this morning. When I feel a cough coming on, I’ve been licking a little cayenne pepper off my hand which stops it. Then when I finally cough, it’s productive. I’ve had a couple of short fits today, but still much better. I realize this is hardly scientific, lol.

I really don’t want to take amitriptyline or any drugs, but I will if nothing “natural” works. I’m researching the heck out of cayenne. I will report back if I have success.

Thank you for your wonderful videos and information. I cried reading and listening like I cried reading the book… it gives me hope that I’m not alone, I didn’t make this up, it’s true that nothing in particular seems to trigger the cough and there are people getting over this. I could be one of them! Blessings.

Thank you very much for your feedback. I’m sorry to hear of your difficulties. What follows is of course speculative as it may or may not apply to you. Keep in mind that I’m trying to give information, and not to diagnose. Only your personal physician can do that.

With that caveat: Acid reflux affecting the larynx is a very important, if sometimes over-used, diagnosis. In your case, there can also be a contribution of a breathing tube injury if it was in for 4 days. Endotracheal tubes can cause granulation in the posterior part of the vocal folds and you can find photos of this on our website and elsewhere. Injuries from breathing tubes often resolve in a few months, but there can be a permanent injury in some.

As for your use of cayenne–good for you! Do let me know if you can find a simple way to use this. I had thought of using hot sauce originally, before hitting upon the idea of a compounding pharmacy. All the best to you.

Thank you for your response. I appreciate the information and perspective so much.

Since I started licking cayenne off my hand, the cough has dramatically decreased. I can still stop an attack with it. I get the urge to cough, lick cayenne, suppress the urge to cough (which I have never done successfully before) until the cayenne reaches my throat… after about 30 seconds, I have one or two productive coughs and it’s over. Nothing short of a miracle in my mind.

I keep cayenne in a sprinkle jar in the kitchen and use that during the day (I work at home). I have a tiny jar of cayenne next to my bed and that’s what I’ll take when I go out. Lick my pinky, dip in and wipe on my tongue. If I use too much and inhale any, makes me cough!

I’m off to teach a seminar today so we’ll see how it goes there. Taking cayenne with me — changes in temp and “office smells” can set it off. I will sometimes cough quite a bit before the day starts while my system gets used to the new environment. Anyway, taking my magic cure with me

I was in the coma for four days but in intensive care with the tube for a total of 10. Then 10 more days in a regular hospital bed. I saw the granulomas on the TV screen in my docs office a couple of months after the hospital (this was all in Costa Rica) — they were at the top of the cords, identical on either side.

I can live with permanent voice damage at this point, as long as my throat and larynx are otherwise healthy. My soprano is totally gone unless I can muscle a little out. There’s a section of my voice that is gone, no sound at all. I’m thinking that might be where the granulomas are, where the cords cannot meet? Wild guess. But I can live with being an alto! I sing with John Prine records now instead of Eva Cassidy — I feel positively lyrical

My voice is already stronger from not coughing constantly. If the coughing continues to improve, I’ll address the voice. Would be nice to know what’s actually happening in there. If there’s something I can do to improve it, I would. It seemed wasted effort to address it with the constant coughing.

Thank you again SO MUCH. I hope the cayenne works for others.

Thanks for the further follow-up. I have already passed your suggestion on to someone who I think is in the UK. What I’ve suggested before is Tabasco, but powder seems more efficient and convenient. Do keep in mind that amitriptyline and gabapentin (to name the two commonest medications for SNC) could be considered, though if cayenne gives you satisfactory relief, no need to look elsewhere.

i know the reason for my chronic cough…a parathyroid adenoma. That will be removed hopefully soon. The cough keeps getting worse. It started as an annoying tickle and now is a persistent irritation. I thought it was GERD, post-nasal drip, seasonal allergies, etc. Antihistamines did not help nor did an inhaler. I am a big fan of hot peppers and would resort to taking a spoonful of my hottest hot sauce (Tabasco is not hot enough) to act as a counter-irritant. I then made my own vinegar-based tincture from red Thai chili peppers and habaneros with a little capsicum oleoresin. This I would dribble into my throat with a dropper with immediate relief.

Another thing that is effective is tramadol. Unfortunately for me, even at the lowest dose, after 1.5 days, my face begins to itch horribly and no amount of antihistamines has any effect. Hmmm…itching or coughing, which is worst? The itching usually starts around my nose. This is funny, to stop the itching, I rub a piece of fresh Thai chili or habanero over the itchy areas. Capsaicin to the rescue again!

I’ll just stick to my hot peppers. I enjoy them, they are natural and the capsaicin works!

Capsaicin is what provides the heat in chili peppers and has been used alternatively as an irritant to induce cough in the pulmonary literature, but also numbness in chronic pain situations.

I, like all of your correspondents, am having problems with my local GP and ENT specialists in believing that my cough is more than reflux and/or allergies. I have always had problems either with nose or throat problems which have mainly been through colds but this last two years have brought on a very annoying cough and blocked nose. This was brought on more earlier this year by having an eye tooth removed where the problem in my nose decreased and my throat became very sensitive and this brought me more into contact with my GPs. They did give me medicine to try and clear my nasal and reflux problems but so far without much luck. Yesterday (17th Sept 2015) the ENT specialist told me there was no more they could do. I then produce a copy of a report on Laryngeal Sensory Neuropathy Chronic Cough which I had taken off the internet and said that the problems that this person was having were the same as what I am suffering, to which he tried to say that there was no evidence of anything working but he would look into it a bit more and possibly pass what he finds on to my GP. I am not holding my breath on this score. According to your site there seems to be a lot which will alleviate if not cure this problem I am hoping so anyway. Thanks for a very informative site. G A

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Since my last notice on this site I have to THANK Sally for her suggestion of cayenne pepper to relieve the coughing. I started doing the little finger dip and after the initial heat feeling it certainly calmed my coughing. I was finger dipping three or four times a day and now I am just doing it when I feel a cough coming on . This may be only once or twice a day but my main relief is the fact that I am now able to have a full night sleep instead of four one and a half hour doses. The reflux has all but disappeared thankfully the only bit I get is when I awake in the morning with a little bit of mucus at the back of my throat which is quickly removed with a small cough. Thanks again Sally. G A

Dr. Bastian,
My cough has been with me for 20 years. Until last year at Mayo Clinic I didn’t have a diagnosis. When watching your web videos, you could be describing me exactly. In the last year I have tried five medications. Gabapentin and Lyrica had little effect. Tricyclic antidepressants gave me such great relief, perhaps 80% improvement but the side effects were dangerous. My blood pressure was affected, giving me near-black outs, rapid heartbeat and breathing. At least these meds confirmed the diagnosis.

I tried the cayenne pepper technique and it does help, disrupting the cough. It’s as if the nerves in my throat are confused and although this is not a good permanent solution, it does offer some diversion from the usual pattern of coughing.

I’m working with my Mayo doctor to determine if I’m a candidate for botox injections. Among other concerns, I understand this is a temporary benefit and I would have to return often, traveling a fair distance for additional treatments.

Is there a SSRI med that has proven helpful? I mentioned it to my doctor but apparently there are no studies connecting it to neuropathic cough.

Your website and this blog are so helpful. Thank you.

First of all, I’m really happy that you are on the right track after 20 years of this miserable cough. Here are some ideas that may or not apply to you, so take them as “educational” and not as medical advice. Some have side effects from tricyclic antidepressants (TCA’s), but can keep them at an acceptable level by keeping the dose very low. So they may get only 50% reduction, but that is at least a start. Not all TCA’s are as prone to side effects. Besides amitriptyline, desipramine or nortriptyline may have fewer side effects of the sort you describe. A few people get very good help from citalopram or venlafaxine. Another medication that helps some a lot is a tetracyclic antidepressant called mirtazapine. Check all of these out with your doctor’s help, and we would be interested to learn what you discover. (I hope you find this information helpful. Please consider Dr. Bastian’s reply to be informational only, and not medical advice; don’t act without your personal physician’s input).

Hello, I have just found this site and found it very interesting and helpful. I live in New Zealand and have had a chronic cough for 24 years. I have done all the tests – too many to mention and also an operation to prevent reflux all to no avail. I have been taking a combination of drugs for the past 2 years and am now taking Omeprazole in the morning before I eat and drink for reflux, Gabapentin 3 times a day, Tramadol 2 times a day and Amytriptiline at night. At first the cough was almost gone but as tim e has gone by and trying to reduce the intake, the cough is returning. I like the idea of using cayenne and will try today. I will let you know how I get on.

Thank you for your comment. Please do update us on your progress. I’m glad you found our website helpful!

I am unable to find capsaicin spray here in New Zealand. Can you advise if there is an online store I can order from?
I have used the cayenne pepper, it does help calm the cough but also makes me nauseous .

Very sorry to hear of your trouble. A woman in England contacted me to say that, unable to find a spray version, she bought a container of cayenne pepper powder. She wets the tip of her little finger, dips it in, and then puts the powder that has adhered into her mouth. She says it helps a lot. Of course you can check with a compounding pharmacy to see if the capsaicin solution for spray could be compounded for you. In that case, I’d suggest using 0.03% percent. The preparation is made using Capsicum Oleoresin- the active (HOT) ingredient extracted from hot peppers. Caution to you is that this is very hot! Use as described in my article. (I hope you find this information helpful. Please consider Dr. Bastian’s reply to be informational only, and not medical advice; don’t act without your personal physician’s input).

Thank you SO much for the names of other medications I might try. I truly appreciate this help.

25 years and progressively worse, and definitely the quality of life is impacted (you don’t go places, you apologize and explain that you aren’t “sick”, you develop bladder issues……and live in constant fear of something that will trigger the cough). I also have been through the inhalers (you have asthma) and testing for acid reflex (nope) and while I have allergies, controlling the drip doesn’t stop the cough. The generic medical belief that it is all in my head….or COPD…. is frustrating. I had thyroid surgery many years ago, and about 20 years ago a really bad bout of something that sat in my throat for a week and required Lidocaine to barely manage to swallow. I am going to try the cayenne …..and I hate pepper and anything spicy, so that tells you how desperate I am to find something that isn’t a heavy drug. I do use something “heavy” when I just can’t stand it anymore…..Hydrocodone Chlorphen ER Suspension. It does help. Expensive and not covered by my drug insurance. Christmas grocery shopping in a minute will include trying cayenne pepper. Am hoping I can go to a movie again…..or not have a coughing/choking attack where people step away, or are ready to call an ambulance.

I am a nurse and have had a chronic cough for 13 years. I’ve been to countless doctors. I’ve been told it’s all in my head, it’s allergies, it’s gerd, it’s asthma and bronchitis. I’ve even been treated like I’m a drug seeker. I just want a normal life. I’ve taken every medicine under the sun. I was finally diagnosed about a year ago. I was started on neurontin but had severe side effects. My second medication was elavil. I am on 150mg at night. I worked great for almost a year. Now my cough is severe again. It interferes with my work and private life. I can’t go to the movies. I can’t go to church. I have severe stress incontenance. My urologist says I need surgery but my cough would just tear up everything he does in surgery. My cough disturbs my sleep and my husband’s sleep. I am going to try the capsaicin spray. If I can’t find any relief I plan to research botox injections.
If anyone has any other advice I would gratefully appreciate it.

I’m sorry to hear of your distress. A few thoughts: First, when amitriptyline works well, but then the benefit fades, it is reasonable to try discontinuing the medication for a week, and then resuming. At the relatively high dose you are taking, I might taper off in steps across ten days, stop for a week, and then gradually begin titration upwards. This often restores the benefit. As for gabapentin, if there was some benefit, I would not give up easily due to side effects. The strategy would be to use 100 mg capsules rather than 300’s. This would allow a very slow long up-titration (dose escalation) over a long period of time. If you take that medication on an empty stomach, side effects are usually much more evident, so consider always taking with food other than the bedtime dose. Finally, QID works better for many people than TID does, so it ends up being breakfast, lunch, dinner, and bedtime… Just to give you hope, the very first person I ever put on gabapentin for this 15 or more years ago, was just started on capsaicin, and she says it is helping tremendously. Keep going! And all the best! (I hope you find this information helpful. Please consider Dr. Bastian’s reply to be informational only, and not medical advice; don’t act without your personal physician’s input).

I have had a chronic cough for 9 years. I have been to every doctor and nobody can seem to find out why I’m coughing. I have been treated for asthma, gerd, I have taken Amiytripline to no avail. I have been given inhalers, steroids, nasal sprays, cough medicines, allergy medicine and nothing stops my cough. It has now caused me to either have a bruised muscle or bruised rib as its really painful to breathe cough sneeze excetera. So now I am on bed rest with ice. It is going to be really hard to heal my muscle due to coughing. I am going to try the Cayenne pepper.

Ive been experiencing a chronic cough that would often times lead to vomiting for 2 years. It started 6 months after experiencing a Pulmonary embolism when I was in recovery and had recently started taking Xarelto. I went through all the normal treatments. Broke 5 ribs and my cough would often times lead to vomiting or sometimes go straight to vomiting. toothpaste, fire or exhaust, scents, hot or cold changes in the air, sitting up from lying down, bending over, eating dry, crunchy, sugary, cold foods, exercise, singing, or talking would bring on an attack. I haven’t heard depression mentioned. I got a second opinion from a pulmonary specialist at the UofW and waited 3 months to get in to see him. He had already read a long package of info sent from my previous pulmonary doc and had determined that she has done a wonderful job and that it was possible that I had developed a tick, that it was likely all in my head and that I needed to do all I could to stop myself from coughing. I couldn’t hold back the tears. My husband was with me and the damage that conversation had was immense. Everything I had been doing and saying to build a network of support of taken away in that moment. My daughter was also with us and we shared the input with her. I would do it different next time. Electing not to have them hear a doctors medical advice. I constantly thought about suicide afterwards. My family delt me the tough love approach the doc had pushed and I suffered the same with the cough, but without the support. It was the toughest time. I finally made another appointment for a sore on my tongue, (with a different primary care doc, bc mine was on vacation) and after listening to me said I should try gabapentin and that my symptoms sounded like they were nerological that I may have suffered some damage to my vagus nerve. My tingling is mostly on my right side of my throat, and if I rub behind and under my ear I can vomit immediately. The gabapentin is helping a lot. I have just recently asked my primary doc to increase the dosage to 1800mg from the 300mg initially given. I am taking acid reflux Meds again to reduce even the smallest irritation. I have been able to get through a movie, dinner at a restarant and even started exercising again. Yesterday I spent the day cleaning and other housework I had been avoiding bc of my coughing. The only thing that was helping me prior to the gabapentin was an over the counter cough suppressant called Fishermans Friend which has a high Menthol content. 11mg vs the normal 3mg or less which is in many other products. If I put one in my mouth right before an appt, it would get me through without an attack. I was going through a package every few days however and it was never reliable. I’m wondering if there aren’t some similarities between the capsaicin and menthol as far as how they work.

Christine, I use Fisherman’s Friend too with great results. Menthol is the active ingredient, but capsicum is an inactive ingredient and I think that is the reason these lozenges work so well. See my post which follows yours.

I Have Meige’s Syndrome including Blepharospasm and Laryngospasm. I get Botox for the Blepharospasm and take Klonipin for the Laryngospasms which works fairly well until I get a respiratory infection with a cough, or if I swallow wrong or smell a strong odor. I have found the use of “Fisherman’s Friend” throat lozenges that contain capsicum to be of tremendous benefit in heading off the tickle-trigger in many instances. These are very strong lozenges and clear the throat and sinuses quickly. They are more expensive than regular lozenges and sometimes hard to find, but they work so well, I buy cases at a time and am never without them.

My issue is Laryngeal Sensory Neuropathic Chronic Cough (SNC) like others on this website… but definitely “cold induced”. Luckily, I live in southern California. My story seems to be like many others on this site. Different doctors, tests, treatments, medications, etc. for the suspected culprits (asthma, post nasal drip from allergies, reflux). Oh my goodness….. What a blessing to find this site! I am not alone and SOMEBODY actually understands what I am going through!! My cough has been haunting me my entire life. It used to be that drinking HOT water and taking cough drops would help. Now, even that is not enough. The last five years have been much worse and have caused me to retire from teaching early. Medications did not work for me. I am currently receiving the Botox treatment. Two weeks ago, I began. It is still difficult to swallow liquids and my coughing is so much worse because I can not complete a cough as I used to. It seems to stretch on and on. My voice is slowly returning. The doctor assured me that at this point in my treatment it is “normal”. I sure hope he is correct because I don’t think I can continue like this for much longer. He said that I must give it a try for two to three rounds of Botox to evaluate if it is working at all. If not, then I will stop. He said that if it shows signs of helping, it could take up to seven rounds of Botox. However, I have read that it could even be up to 16. I will try the cayenne pepper tomorrow.

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This is Ronda Kalan again. In my comment (above) I meant to ask if ANYONE has the same situation of the cough being cold induced. Also, does anyone know of a specialist in this field in Los Angeles or nearby. Although, I have already begun my Botox treatment, I would like a second opinion or to hear someone who has a different suggestion.
Thank you,
Ronda

Hi Ronda, it looks like the comments on this site have slowed down and been taken over by ads. Did you end up finding relief? Cold air is definitely one of my triggers, and I live in the Sierras. I have worked with my gp and an allergy specialist and finally am finding relief on 60 mg day nortriptyline spaced out at 8 hour intervals. This is the fourth morning I have not had a violent cough after waking–after years and years. Still have a few cough fits during day, but much reduced. So excited. I do feel sleepier and less alert on the drug , but at this point the relief is worth it.

Cbd oil for neurogenic cough

Corry de Neef 1 , Sonia Fullerton 1*

Parkville Integrated Palliative Care Service, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia

* Corresponding Author: Dr. Sonia Fullerton, Parkville Integrated Palliative Care Service, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australi

Received: 01 September 2020; Accepted: 14 September 2020; Published: 09 October 2020

Citation: Corry de Neef, Sonia Fullerton. Cannabis for Treatment of Intractable Malignant Cough- A Case Report. Journal of Cancer Science and Clinical Therapeutics 4 (2020): 457-461.

Abstract
Keywords

Chronic cough; Cannabis; Pneumothorax; Cancer

Article Details
1. Introduction

Chronic cough is not uncommonly experienced by patients with cancer. Chronic cough can be a disruptive and exhausting symptom, reported as being very distressing in a quarter of those in the last year of life [1]. Severe cough has an impact on the patient and family in physical, psychological and social domains. Cough can cause issues such as urinary incontinence, syncope, headache, retinal and conjunctival haemorrhage, pneumothorax, pain from fractured ribs and injured muscles, and haemorrhoids [2]. In addition, cough is disruptive to the patient and their family, and can be embarrassing in public. It can interfere with all aspects of function and reduces quality of life [3].

Many cancer symptoms are well managed in clinical practice, but the common symptom of cough has little high level evidence to guide its management. Health professionals use inconsistent approaches to manage cough [3].

There are many possible causes of cough, which can be

  1. directly related to malignancy such as primary disease, metastases, and lymphangitis carcinomatosis;
  2. indirectly related to the malignancy such as infections, pleural effusions and pulmonary emboli; and
  3. conditions not related to cancer, such as asthma, chronic obstructive pulmonary disease, gastro-oesophageal reflux disease with micro-aspiration, or medications such as bleomycin, methotrexate and angiotensin converting enzyme inhibitors (ACEIs).

The range of treatments commonly offered include

  1. non-pharmacological options such as smoking cessation and saline nebulisers;
  2. treatments specific to the cause of the cough, such as anti-cancer treatment, antibiotics or beta 2 agonists; and
  3. non-specific treatments acting on the lungs, pharynx or nervous system such as anti-tussives, opioids, pregabalin and paroxetine [4, 5].
2. Case Report

MJ was diagnosed with adenocarcinoma of the rectum at the age of 38 after presenting with a 2 year history of altered bowel habit. He was initially treated with neo-adjuvant capecitabine and radiotherapy. Surgery was delayed until 6 months after diagnosis when a robotic ultralow anterior resection with coccygectomy and IGAM (inferior gluteal artery myo-cutaneous island) flap was performed. At surgery, he was found to have 3 synchronous tumours and 1/19 lymph nodes were positive for adenocarcinoma.

Sixteen months after surgery, restaging scans demonstrated new avid retroperitoneal, retrocrural, posterior mediastinal and subpleural nodules. He was still asymptomatic and continued to work as a truck driver. Two years after surgery, he was found to have enlarging pulmonary and pleural nodules and lymphangitis carcinomatosis. He commenced palliative FOLFOX (Folinic acid, 5 fluoro-uracil and Oxaliplatin). He was commenced on a course of Dexamethasone which led to diabetes, which did not resolve when steroids were ceased. He stopped working at around this time.

Two months later, he complained of dyspnoea, anorexia and intractable, occasionally productive cough, which had been present for several weeks. He was found to have metastatic disease in the lungs with multiple segmental and sub segmental pulmonary emboli.

The cough was debilitating. He coughed while eating and speaking, making both difficult. He coughed while asleep and cough would disturb his sleep. Episodes of coughing could be associated with breathlessness and occasionally vomiting. It was not altered by posture and did not respond to over the counter anti-tussives, or regular use of inhaled saline, bronchodilators or steroids. Morphine liquid was commenced, even though pain was not an issue, but although it helped initially, it was soon ineffective, and he reduced the dose himself. Codeine linctus was no more effective than morphine. He was taking mirtazapine to stimulate appetite, and this was changed to paroxetine as there is limited case evidence that demonstrated efficacy in cough [4, 5]. However, three months later his cough was unchanged.

He and his wife asked about trying medicinal cannabis for his symptoms, especially poor sleep, poor appetite and vomiting. He had never used cannabis in any form in the past, consistent with survey data on the use of medicinal cannabis in cancer patients [6]. He had been a smoker, but successfully stopped in the first year post diagnosis. The possible role of medicinal cannabis in his situation was discussed. As a way of trying cannabis before investing in medicinal cannabis, a family member obtained some recreational marijuana. His wife converted it to marijuana butter following a recipe found on the internet and baked the butter into rum balls.

On a weekend night (day 0) he ate two rum balls. After noticing no effect in two hours, he ate a further three. Within another hour, he was severely intoxicated from the marijuana. His family were amused by his behaviour, but he soon went to bed and slept without disturbance until mid-morning, which had not occurred for several months. It was not until he had been awake for an hour or so, and he was having breakfast, when his partner mentioned that he had not coughed. In fact, his cough remained absent for over a week. He did not consume any further rum balls.

Eight days after eating the rum balls, another consultation occurred by telehealth. The cough had just started to return the previous day, but the difference from the previous consultation was remarkable. In the entire 30 minute consultation, he only had an occasional cough. During this time, the only other medication commenced was metronidazole for halitosis.

3. Management and Outcome

MJ decided that he did want to try medicinal cannabis to assist with his symptoms of insomnia and improve his general wellbeing. Permits were obtained to prescribe Tilray 10:10 Full Spectrum cannabis oil, which contained 10mg/ml tetrahydrocannabinol (THC) and 10mg/ml cannabidiol (CBD) with traces of other cannabinoids. The 1:1 ratio of THC and CBD is not the same ratio as would be found in most recreational marijuana, which would normally have a much higher ration of THC to CBD.

Three weeks after taking the rum balls MJ had another telehealth consultation. During the telehealth consultation MJ was coughing persistently, holding a towel to his face and occasionally retching after coughing.

Four weeks after day 0, he commenced the medicinal cannabis at 0.25 ml nocte and slowly up titrated the dose. At the next consultation, 6 weeks after day 0, he was taking 0.25 mls mane and 0.5 mls nocte. He reported a significant improvement in the cough. He found higher doses made him feel drugged and drowsy during the day. By altering the dosing schedule, taking a lower dose in the morning and a higher dose at night, he was able to function during the day and supress the cough so that he was also sleep at night. Medical notes at the time report that the reduction in cough was an unexpected effect of the medicinal cannabis and that “the cough reduction shows dose dependency”. The dose of slow release Morphine which had been commenced for cough was reduced at this consultation.

MJ reported that when his supply of medicinal cannabis at home was running out, he had reduced the dose himself for a period of time. During that time, the cough worsened. At the next consultation, 8 weeks after day 0, the cough was still present, but not as severe as prior to using the cannabis oil. Over time, the dose of cannabis oil increased. At his last consultation, 12 weeks after day 0, he was taking Tilray 25:25 Full Spectrum cannabis oil (THC 25 mg/ml and CBD 25 mg/ml), 0.25mls mane and 0.5 mls nocte with an occasional dose of 0.25 – 0.5mls in the middle of the day. MJ died peacefully at home 4 months after commencing medicinal cannabis.

4. Discussion

The cough is a common symptom in many diseases and its aetiology can includes benign and malignant causes in multiple systems. Often by the time a patient with severe cough first presents for specialist review, they have already tried several over-the-counter anti-tussives, and some of the commonly used prescribed drugs such as beta-2 agonists, inhaled corticosteroids, and opioids. A Cochrane review titled “Interventions for cough in cancer” [7] in 2015 could not offer any practice guidelines ‘as evidence was limited and of the lowest quality.’ The 2010 and 2015 Cochrane reviews suggested that further studies of cough treatments were urgently needed. The American College of Chest Physicians in 2017 [3], suggested the following graded intervention, although none with strong evidence.

  1. Comprehensive assessment to identify co-existing causes linked with cough and treat accordingly.
  2. Cough suppression exercises as an alternative treatment or in addition to pharmacological intervention.
  3. Endobronchial brachytherapy for suitable tumours.
  4. Demulcents (agents that form soothing protective films when administered onto a mucous membrane e.g. butamirate linctus, simple linctus or glycerin-based linctus.
  5. Opiate derivatives e.g. codeine, morphine, methadone, dextromethorphan, pholcodine.
  6. Nebulised lidocaine or bupivacaine.
  7. N-of-1 trials of other drugs, which have not been definitively shown to be effective nor devoid of adverse effects e.g. diazepam, gabapentin, carbamazepine, baclofen, amitriptyline, thalidomide.

Other agents with limited evidence include aprepitant [8, 9] and paroxetine [4, 5]. There are no recent human studies or case series using cannabis in the management of cough, in spite of pre-clinical evidence suggesting a role for cannabinoids in cough. Short-term smoking of marijuana is associated with bronchodilatation while long-term smoking is associated with increased respiratory symptoms suggestive of obstructive lung disease [10].

There is a physiological rationale as to why cannabis may have a role in the suppression of cough. The cough reflex is regulated by G-protein coupled receptors. Agonists of prostanoid receptors and agonists of bradykinin receptors stimulate cough, whereas beta-adrenoceptor agonists and cannabinoids suppress cough [11]. The CB2 receptor is particularly implicated as a site of action for anti-tussives as selective blockade of the CB2 receptor reduces the anti-tussive effect in guinea pigs and human sensory nerves in the airways [12]. This has implications for the development of novel anti-tussives, as CB2 receptors are not expressed in the CNS to the same extent as CB1 receptors [13]. Hence selective CB2 agonists may avoid the psycho-stimulatory adverse effects of non-specific cannabinoids [14].

The case of MJ is interesting, not only because the effect of cannabis on cough was unexpected to both patient and clinician, but also because the effects of recreational marijuana and medicinal cannabis could be compared. In addition, the effect seemed to be dose responsive over time, with the patient and wife reporting that when they decreased the dose, the cough increased in severity. The anti-tussive effect was seen with both recreational and medical forms of cannabis, and the patient was clear that there was a dose response with higher doses causing more adverse effects, but also being more effective for cough.

It can be difficult to assign causation in the setting of a single retrospective case report. However, in MJ, who had not used any form of cannabis previously, only two changes occurred around the time of the dramatic improvement in his cough-the introduction of metronidazole for management of halitosis and introduction of cannabis for management of poor appetite and insomnia. The fluctuation in the impact of the cough mirrored the dose of cannabis, as did the adverse effects of feeling drugged and sedated. Chronic cough in the setting of malignant disease is a common problem that has a significant impact on the person’s quality of life, with little evidence to guide therapy to reduce its severity. Further investigation of the role of medicinal cannabis in the management of intractable cough is warranted.