What causes morning coughs?

Causes of Morning Coughs

Morning coughs are primarily caused by postnasal drip syndrome (now called upper airway cough syndrome), gastroesophageal reflux disease, and asthma, which together account for over 90% of chronic cough cases including those that occur predominantly in the morning. 1

Common Causes of Morning Cough

Upper Airway Cough Syndrome (UACS)

• UACS (previously called postnasal drip syndrome) is one of the most common causes of chronic cough, including morning cough, accounting for approximately 57.6% of cases 2
• During sleep, mucus accumulates in the back of the throat and upper airways, leading to coughing upon waking as the body attempts to clear these secretions 1
• The cough is often associated with frequent throat clearing or the sensation of postnasal drip 1

Gastroesophageal Reflux Disease (GERD)

• GERD is responsible for approximately 41% of chronic cough cases 2
• A cough that abates overnight may be due to reflux (closure of the lower oesophageal sphincter during sleep) 1
• Morning cough from GERD occurs because refluxed stomach contents irritate the throat and airways during the night, with symptoms manifesting upon waking 1
• GERD can cause cough without typical gastrointestinal symptoms (silent GERD) in up to 75% of cases 1
• Cough related to GERD may be worse after meals or when lying down 1

Asthma

• Asthma accounts for approximately 59% of chronic cough cases 2
• Asthma can cause coughing that wakes patients during the night or early morning 1
• Morning cough in asthma is often related to circadian variations in airway responsiveness 1
• Exercise or exposure to cold air can worsen cough in patients with asthma 1

Other Contributing Factors

Smoking

• One of the most common causes of persistent cough, including morning cough, is smoking 1
• The prevalence of chronic cough is increased in smokers in a dose-related manner 1
• Smoking cessation initially leads to a short-term increase in cough reflex sensitivity before improvement 1

Sleep-Related Factors

• Sleep is known to suppress the cough reflex, particularly during deep sleep (stages 3 and 4) 1
• Ambulatory recordings have shown a marked reduction in cough overnight 1
• Upon waking, the cough reflex returns to normal sensitivity, which may trigger morning coughing 1

Environmental Irritants

• Accumulation of environmental irritants in the bedroom (dust, allergens, dry air) can trigger morning cough 1
• Changes in air temperature from warm bed to cooler room can trigger cough in those with a sensitized cough reflex 1

Medications

• ACE inhibitors can alter the sensitivity of the cough reflex and contribute to chronic cough, including morning cough 1

Clinical Pearls and Pitfalls

• The character and timing of cough (including morning predominance) are not reliable diagnostic indicators of the underlying cause 3, 1
• Multiple causes often coexist - in 61.5% of patients with chronic cough, multiple factors contribute simultaneously 2
• The triad of UACS, asthma, and GERD (alone or in combination) is responsible for 93.6% of chronic cough cases 2
• Women, particularly middle-aged women, have a higher prevalence of chronic cough and more sensitive cough reflex 1
• A common pitfall is assuming that absence of typical symptoms rules out a diagnosis (e.g., absence of heartburn doesn't rule out GERD as a cause of cough) 1
• Cough that occurs predominantly in the morning should still be evaluated systematically rather than attributing it to a single cause based solely on timing 1, 3

Diagnostic Approach

• Consider the clinical profile of the patient: smoking status, medication use (especially ACE inhibitors), and chest radiograph findings 1
• Evaluate for the three most common causes (UACS, GERD, asthma) even when the cough is predominantly in the morning 1
• Look for specific triggers that may worsen morning cough, such as posture changes, eating patterns, and environmental exposures 1
• Consider less common causes if the three main causes have been ruled out or treated without success 1