Is tramadol (ultram) effective for treating neurogenic cough?

Tramadol for Neurogenic Cough

Tramadol appears to be effective for treating neurogenic cough and should be considered as a therapeutic option for patients with this condition. 1

Understanding Neurogenic Cough

• Neurogenic cough is characterized by a postviral chronic cough with paroxysms triggered by a tickle sensation that is often resistant to conventional treatments for reflux disease, sinus disease, and asthma 2
• It is considered a neuropathic condition potentially caused by sensory nerve damage from inflammatory, infective, or allergic factors 3
• The condition likely involves sensory neuropathy of the internal branch of the superior laryngeal nerve (SLN) 4

Treatment Algorithm for Neurogenic Cough

First-Line Approaches:

1. Trigger reduction strategies:

   • Nasal saline irrigation, nasal steroids, nasal antihistamines 2
   • Plant-based diet with alkaline water to reduce laryngopharyngeal reflux triggers 2
   • These approaches have shown significant improvement in cough severity index (CSI) scores (59.8% reduction) 2

2. Neuromodulators:

   • Gabapentin is recommended as a first-line neuromodulator for unexplained chronic cough 5
   • Start with low doses and titrate up while monitoring for side effects such as confusion, dizziness, dry mouth, fatigue, and nausea 5

Second-Line Options:

1. Tramadol:

   • Demonstrated effectiveness in neurogenic cough with significant improvements in both cough severity index (CSI) and Leicester Cough Questionnaire (LCQ) scores 1
   • Acts through dual mechanisms: weak μ-opioid receptor agonist and inhibition of norepinephrine and serotonin reuptake 6
   • Maximum recommended daily dose is 400 mg for immediate-release formulations or 300 mg/day for extended-release formulations 6

2. Other interventional approaches:

   • Superior laryngeal nerve block has shown efficacy with significant reduction in CSI scores from 26.8 to 14.6 4

Important Considerations with Tramadol

• Serotonin syndrome risk: Exercise caution when combining tramadol with other serotonergic medications (TCAs, SSRIs, MAOIs) 6
• Adverse effects: Common side effects include dizziness, nausea, sedation, dry mouth, and sweating 7
• Advantages over traditional opioids:
  • Lower respiratory depression risk 7
  • Lower dependence potential in short-term use (up to 6 months) 7

Monitoring and Follow-up

• Assess response using validated tools such as the Cough Severity Index (CSI) and Leicester Cough Questionnaire (LCQ) 1
• Monitor for adverse effects, particularly when initiating therapy 7
• For patients with multiple triggers, reassess the need for continued trigger reduction strategies 2

Clinical Pearls

• Tramadol offers a viable alternative to traditional opioids for neurogenic cough with potentially fewer respiratory side effects 7
• The dual mechanism of action (opioid and monoaminergic) may specifically target the neuropathic component of chronic cough 6, 3
• Consider tramadol particularly when gabapentin has failed or is contraindicated 5, 1
• Be vigilant about potential drug interactions, especially with other serotonergic medications 6