What is the recommended management for functional heartburn?

Functional Heartburn Treatment

Functional heartburn requires neuromodulators (tricyclic antidepressants or SSRIs) as primary therapy, with PPIs having no therapeutic value except when proven GERD overlaps with functional heartburn. 1

Diagnostic Confirmation Required Before Treatment

Before initiating treatment for functional heartburn, you must confirm the diagnosis through objective testing, as this fundamentally changes management from typical GERD:

• Upper endoscopy with esophageal biopsies to exclude erosive esophagitis, Barrett's esophagus, and eosinophilic esophagitis 1, 2
• High-resolution esophageal manometry to rule out major motor disorders like achalasia 1
• pH monitoring off PPI therapy (or pH-impedance on therapy if proven GERD exists) demonstrating physiologic acid exposure with negative symptom-reflux association 1, 2
• Diagnosis requires symptoms persisting despite double-dose PPI therapy taken appropriately before meals for 3 months 1

The distinction from GERD is critical: functional heartburn does not meet the Montreal definition of GERD because it lacks either troublesome reflux or tissue injury 3. This is why PPIs fail—there is no acid-mediated pathology to suppress 1, 4.

Primary Pharmacological Treatment

First-Line: Neuromodulators

Tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) are the primary therapy because the underlying pathophysiology involves esophageal hypersensitivity and altered pain perception, not acid reflux 3, 1, 4:

• Start with low-dose TCA (e.g., amitriptyline 10-25 mg at bedtime, titrating up as tolerated) 3, 1
• Alternative: SSRI if TCA side effects are intolerable 3, 1
• These medications modulate visceral pain perception and have demonstrated benefit in esophageal hypersensitivity 3, 4

Additional Pharmacological Options

• Tegaserod may provide benefit as primary or add-on therapy 1
• H2-receptor antagonists can be used as adjunctive therapy 1
• PPIs should be discontinued in pure functional heartburn as they provide no benefit and expose patients to unnecessary long-term risks 1, 4

Critical caveat: If functional heartburn overlaps with proven GERD (documented by prior positive pH study, erosive esophagitis, Barrett's esophagus, or esophageal ulcer), continue PPI therapy while adding neuromodulators for the functional component 1.

Non-Pharmacological Interventions

Evidence-Based Complementary Therapies

• Hypnotherapy (specifically esophageal-directed hypnotherapy) shows consistent improvement in heartburn symptoms, quality of life, and esophageal hypervigilance after 7 weekly sessions, regardless of hypnotizability 3, 1, 5
• Acupuncture may benefit as monotherapy or adjunctive therapy 1
• Cognitive behavioral therapy may help patients with underlying psychosomatic disorders, though no RCTs demonstrate benefit 3

Lifestyle Modifications (Limited Role)

Unlike GERD, lifestyle modifications have minimal evidence in functional heartburn, but consider:

• Weight loss only if patient is overweight/obese, as this may address any coexisting reflux component 3
• Relaxation training and abdominal breathing exercises have shown some benefit in small studies 3

What NOT to Do

Anti-reflux surgery and endoscopic GERD treatments have no therapeutic benefit in functional heartburn and should not be recommended 1. This is a critical pitfall—these patients often undergo unnecessary fundoplication after failed medical therapy, which predictably fails because the problem is not mechanical reflux 1.

Management Algorithm

1. Confirm diagnosis with endoscopy, manometry, and pH testing off PPI 1, 2
2. Discontinue PPIs (unless proven GERD overlap exists) 1
3. Initiate low-dose TCA or SSRI as primary therapy 3, 1
4. Add H2RA or tegaserod if partial response 1
5. Consider hypnotherapy or acupuncture as adjunctive therapy 1, 5
6. Provide reassurance and avoid excessive testing or invasive procedures 2

Common Pitfalls

• Continuing to escalate PPI therapy when functional heartburn is the diagnosis wastes time and resources while exposing patients to medication risks 1, 4
• Referring for anti-reflux surgery without proper diagnostic workup leads to failed surgery and worsened quality of life 1
• Failing to recognize psychological comorbidity (depression, anxiety, somatization) that commonly accompanies functional heartburn and requires integrated treatment 4, 2
• Performing excessive invasive testing after diagnosis is established—provide reassurance and focus on neuromodulation 2

The key distinction is recognizing that functional heartburn represents a disorder of esophageal hypersensitivity and altered pain perception, not acid-mediated injury, requiring fundamentally different treatment targeting pain modulation rather than acid suppression 3, 1, 4.