Chronic Cough with Morning Nausea and Gagging/Vomiting
Your symptoms strongly suggest gastroesophageal reflux disease (GERD) as the primary culprit, which can present without typical heartburn in up to 75% of cases and commonly causes both chronic cough and morning nausea with gagging. 1, 2
Most Likely Diagnosis: GERD-Related Chronic Cough
GERD is one of the three most common causes of chronic cough (defined as lasting >8 weeks) and frequently presents as "silent GERD" without classic gastrointestinal symptoms. 3, 2 The combination of chronic cough with morning nausea and gagging/vomiting is particularly characteristic of reflux disease because:
- Refluxed stomach contents irritate the throat and airways during the night when lying flat, with symptoms manifesting upon waking 4
- Morning nausea and gagging occur as accumulated refluxate triggers the gag reflex upon awakening 1, 4
- The cough may worsen after meals or when lying down, though this is not always present 4
The "Pathogenic Triad" to Evaluate
While GERD appears most likely given your specific symptom pattern, you must systematically evaluate all three conditions that account for over 90% of chronic cough cases: 3, 2, 5
1. Gastroesophageal Reflux Disease (GERD)
- Do NOT assume you need heartburn to have GERD—up to 75% of GERD-related chronic cough occurs without typical GI symptoms 1, 2
- Laryngoscopy may reveal posterior laryngitis with red arytenoids and interarytenoid mucosa changes 1
- Treatment trial with proton pump inhibitors is both diagnostic and therapeutic 3, 6
2. Upper Airway Cough Syndrome (UACS, formerly postnasal drip)
- Mucus accumulates in the back of the throat during sleep, triggering morning cough and throat clearing 4, 2
- Look for sensation of postnasal drip, frequent throat clearing, or rhinosinus symptoms 4, 2
- Can be completely "silent" apart from the cough itself 3, 2
3. Asthma (including cough-variant asthma)
- May present with cough as the only symptom, without wheezing or dyspnea 3, 2
- Morning cough can occur due to circadian variations in airway responsiveness 4
- Requires pulmonary function testing and possibly bronchoprovocation testing 7, 5
Critical Diagnostic Steps
Obtain these specific historical elements: 2
- Medication history: Are you taking an ACE inhibitor? (Common cause of chronic cough) 4, 2
- Smoking status: Current or former tobacco use? 2, 8
- Red flag symptoms: Fever, night sweats, unintentional weight loss, hemoptysis? 2, 7
- Geographic exposure: Areas endemic for tuberculosis or fungal diseases? 2
- Past medical history: Previous cancer, tuberculosis, or AIDS? 2
Initial diagnostic workup should include: 7, 5
- Chest radiograph to rule out serious pathology 3, 7
- Pulmonary function testing 7, 5
- Consider CT of paranasal sinuses if UACS suspected 5
- 24-hour esophageal pH monitoring if GERD strongly suspected but empiric treatment fails 5
Common Pitfalls to Avoid
- Do NOT rely on cough character, timing, or sputum production for diagnosis—these features have NO diagnostic value 3, 2
- Do NOT assume absence of heartburn rules out GERD—this is the most common mistake 1, 2
- Do NOT search for a single cause—in up to 61.5% of patients, multiple conditions coexist and ALL must be treated 5
- Do NOT overlook that even significant sputum production in a nonsmoker with normal chest X-ray typically still results from UACS, asthma, or GERD 3, 2
Treatment Approach
Begin empiric treatment for GERD given your symptom constellation: 6, 5
- High-dose proton pump inhibitor therapy (twice daily) for 8-12 weeks minimum 6
- Elevate head of bed, avoid late meals, dietary modifications 6
- If no response after 8 weeks, systematically address UACS and asthma 3, 6
If initial treatment fails, consider that 61.5% of chronic cough patients have multiple simultaneous causes requiring treatment of all identified conditions. 5 You may need combination therapy targeting GERD, UACS, and asthma together. 3, 5
Only after systematically evaluating and treating these three common causes should uncommon etiologies be considered. 3