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  • Updated 10.21.2020
  • Released 01.27.2004
  • Expires For CME 10.21.2023

Cough syncope

Introduction

Overview

In this article, the author explains the clinical presentation, pathophysiology, diagnostic workup, and management of cough syncope. Patients with cough syncope are predominantly muscular, overweight, middle-aged men who are current or ex-smokers and who tend to overindulge in alcohol. The vast majority of these patients have a chronic cough, bouts of severe coughing, and evidence of obstructive lung disease. Management of cough syncope focuses on treatment of the cough (eg, bronchodilators and antitussives) and the underlying conditions. Smoking cessation is closely associated with decreased symptoms and should be strongly encouraged. The long-term prognosis of cough syncope depends largely on the prognosis of the underlying condition, but cough syncope itself can result in severe bodily injury, including vertebral artery dissection.

Key points

• Cough syncope patients are predominantly muscular, obese, middle-aged men who are current or ex-smokers and tend to overindulge in alcohol.

• Several (not necessarily mutually exclusive) pathophysiologic processes may cause or contribute to cough-related syncopes, including Valsalva-induced decreased cardiac output, increased intracranial pressure, cardiac arrhythmias, stimulation of a hypersensitive carotid sinus, cough-triggered neural reflex-mediated hypotension-bradycardia, laryngospasm, augmentation of left ventricular outflow obstruction, impaction of a brainstem herniation, decreased cerebral blood flow, internal jugular vein valve insufficiency, and rarely seizures.

• Management of cough syncope focuses on treatment of the cough (eg, bronchodilators and antitussives) and the underlying conditions, but cardiac function, blood pressure, blood volume, reflex-mediated changes, and extracranial vascular patency may all require separate management.

• Smoking cessation is closely associated with decreased symptoms and should be strongly encouraged.

• The long-term prognosis of cough syncope depends largely on the prognosis of the underlying condition, but cough syncope itself can result in severe bodily injury, including vertebral artery dissection.

Historical note and terminology

Although apparently known to British physician William Heberden (1710 to 1801) in the late 18th century (40), French neurologist Jean-Martin Charcot (1825 to 1893) first clearly described cough syncope in the 1870s and labeled it “laryngeal vertigo” (16; 17).

Charcot attributed the symptoms to a reflex irritation of the laryngeal nerves. Later authors generally attributed the symptoms to “laryngeal epilepsy” until around World War II when British military physician Sir Alan Filmer Rook (1892 to 1960) and others suggested cardiovascular mechanisms (101; 83). At that time, Rook was Air Vice-Marshall in the Royal Air Force and Honorary Physician to the King of England.

This article will focus on cough syncope; hiccup syncope (30) and sneeze syncope (19) are less common but closely allied conditions that apparently operate through similar pathophysiologic mechanisms.

Cough syncope is 1 of the so-called situational syncopes, which occur immediately after precipitating situations, such as urination, defecation, cough, or swallowing (12). Generally, such situational syncopes are considered forms of neurally mediated syncope with reflex-mediated vasodilation or bradycardia (12; 32), but other mechanisms can also be involved.

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