What could be causing a dry cough at night that makes it hard to speak?

Dry Cough at Night with Difficulty Speaking: Causes and Approach

The most likely causes of your dry cough at night with difficulty speaking are gastroesophageal reflux disease (GERD), laryngeal hypersensitivity syndrome (which includes vocal cord dysfunction), or upper airway cough syndrome (postnasal drip), with GERD being particularly suspect given the nocturnal timing and voice impact. 1, 2

Primary Causes to Consider

Gastroesophageal Reflux Disease (GERD)

• GERD is the second most common cause of chronic dry cough and can occur without any heartburn or digestive symptoms in up to 75% of cases (called "silent GERD). 1
• The cough occurs because stomach acid refluxes into the esophagus during the night, stimulating an esophageal-bronchial reflex that triggers coughing even without aspiration into the lungs. 1
• GERD-related cough typically worsens at night when lying down, as gravity no longer helps keep stomach contents down. 2
• The voice difficulty occurs because refluxed acid irritates the larynx (voice box), causing inflammation of the vocal cords and surrounding structures. 1
• Importantly, neither the dry character of the cough nor its nocturnal timing rules out or confirms GERD as the cause—these features are not predictive. 1

Laryngeal Hypersensitivity Syndrome / Vocal Cord Dysfunction

• This functional disorder presents with chronic dry cough, throat tightness, and voice changes (dysphonia) due to reversible changes in laryngeal function rather than structural damage. 1
• The condition involves heightened sensitivity of the larynx, leading to excessive throat clearing, sensation of mucus buildup or dry throat, and difficulty speaking due to pharyngolaryngeal tension. 1
• Vocal cord dysfunction can coexist with other conditions and may be triggered by irritants, stress, or become a learned habitual pattern. 1, 3
• The voice difficulty stems from abnormal vocal cord movements and excessive muscle tension, not irreversible structural damage. 3

Upper Airway Cough Syndrome (Postnasal Drip)

• Mucus accumulates in the back of the throat during sleep, leading to coughing upon waking and throughout the night as the body attempts to clear these secretions. 2
• This is often associated with frequent throat clearing and sensation of postnasal drip. 2
• The accumulated mucus can affect voice quality and make speaking difficult. 2

Key Diagnostic Clues

Look for these specific features to narrow the diagnosis:

• GERD indicators: Cough worse after meals or when lying down, hoarseness especially in the morning, sensation of something stuck in throat, sour taste (though remember 75% have no GI symptoms). 1, 2
• Laryngeal hypersensitivity indicators: Throat tightness, sensation of lump in throat, excessive throat clearing, voice breaks or strain when speaking, triggers include talking, laughing, or temperature changes. 1
• Upper airway syndrome indicators: Sensation of mucus dripping down the back of throat, need to clear throat frequently, nasal congestion or discharge. 2
• Medication history: ACE inhibitors (blood pressure medications ending in "-pril") can cause persistent dry cough and should be discontinued if present. 2, 4

Critical Pitfalls to Avoid

• Do not assume that absence of heartburn rules out GERD—up to 75% of GERD-related cough occurs without typical digestive symptoms. 1
• Do not assume nocturnal cough automatically means GERD or asthma—the timing and character of cough do not reliably predict the cause. 1
• Cough typically stops once you fall into deep sleep regardless of cause, so absence of coughing during deep sleep does not rule out any particular diagnosis. 1, 2
• Women, particularly middle-aged women, have more sensitive cough reflexes and higher rates of chronic cough. 2

Recommended Action Plan

Step 1: Medication Review

• If taking an ACE inhibitor (lisinopril, enalapril, ramipril, etc.), discuss discontinuation with your doctor—cough resolves within 3-7 days after stopping. 2, 4

Step 2: Trial of GERD Treatment

• Given the high likelihood of silent GERD with nocturnal dry cough and voice symptoms, a 3-month trial of aggressive acid suppression (proton pump inhibitors) plus lifestyle modifications is warranted. 1, 5
• Elevate head of bed, avoid eating 2-3 hours before bedtime, avoid trigger foods. 1

Step 3: Evaluation by Appropriate Specialist

• If GERD treatment fails or voice symptoms are prominent, referral to ENT (ear, nose, throat specialist) for laryngoscopy to visualize the vocal cords is essential. 1
• If laryngeal hypersensitivity syndrome or vocal cord dysfunction is confirmed, speech therapy with breathing retraining is the primary treatment. 1, 3
• Respiratory physician evaluation with spirometry should be performed to rule out asthma and assess for variable inspiratory flow limitation seen in vocal cord dysfunction. 1, 3

Step 4: Symptomatic Relief During Evaluation

• Dextromethorphan (60 mg for maximum effect) provides cough suppression with fewer side effects than codeine. 4, 6
• Adequate hydration and menthol lozenges can provide short-term relief. 4
• First-generation antihistamines like chlorpheniramine can help if postnasal drip is suspected and the sedation may help with nighttime cough. 6

Important Context

The combination of dry cough at night plus difficulty speaking strongly suggests laryngeal involvement, either from acid reflux irritating the voice box or from a functional disorder affecting vocal cord movement. 1 Both conditions are treatable but require different approaches—GERD needs acid suppression while laryngeal hypersensitivity syndrome needs speech therapy and behavioral techniques. 1, 3 Systematic evaluation starting with the most common causes (GERD, upper airway syndrome, asthma) will identify the problem in over 90% of cases. 2