Timothy C. Hain,
MD Page last modified:
September 28, 2015
Cough Syncope defined Causes Evaluation Index
Cough syncope is a syndrome in which dizziness or syncope occurs after prolonged bouts of cough. See also the syncope page, if symptoms are not particular associated with a cough or hiccup.
Cause of cough syncope:
- Normal or exaggerated response to forceful cough.
- Abnormally sensitive cardio-depressor response to Valvalva (straining)
- Chiari Malformation
Cough syncope patients do not exhibit more pronounced hypotension in response to cough than other fainters, but they also manifest an inappropriate cough-triggered blood pressure-heart rate relationship. These findings argue in favor of the importance of a neurally mediated reflex contribution to symptomatic hypotension in cough syncope.
(Benditt, D. G., N. Samniah, et al.; 2005).
It is well known that cough syncope may occur in the Arnold-Chiari malformation (Ireland, P. D., D. Mickelsen, et al. (1996)). This is probably due to impaired autonomic regulation.
A related entity to cough syncope is hiccup syncope. This is largely associated with lesions of the medulla, and thus is similar to cough syncope. Sueyoshi et al reported a single case, and suggested it was due to stimulation of the glossopharyngeal nerve. (Sueyoshi, Shin, & Nakashima, 2013). Another case occurred after a brainstem stroke (Takazawa et al., 2014). A third case was associated with a small lesion in the brainstem (Shibazaki, Kurokawa, Murakami, & Sunada, 2006). Two cases were reported in MS, again involving the medulla (Funakawa & Terao, 1998; Sakakibara, Mori, Fukutake, Kita, & Hattori, 1997). In summary, is known about hiccups and syncope, but what little has been written suggests that it usually is from a brainstem source.
Evaluation of cough syncope:
Physical examination should include at a minimum
- blood pressure and pulse, standing and supine
- cardiac exam
- Carotid sinus testing
- Check pulse and ideally blood pressure during Valsalva and coughing.
Routine Laboratory Testing:
- Autonomic testing, including tilt-table
- The tilt table test should include a valsalva and coughing to simulate the situation.
- MRI (for Chiari malformation)
- 24 hour holter (for sick-sinus).
- EEG -- should be normal. It may be helpful to exclude seizures. (Gelisse, P. and P. Genton (2008)
According to Chao, A. C., R. T. Lin, et al. (2007). Cough syncope patients often exhibit absent BP overshoot following the relief of straining.
According to Choi, Y. S., J. J. Kim, et al. (1989). Sinus arrest may play a role as a mechanism of cough syncope in a patient with sick sinus syndrome, and 24 hour holter monitoring may be helpful in making this diagnosis.
Most effort is aimed at treating the cough with cough suppressants, and exhaling before coughing.
If the patient has an central or peripheral dysautonomia, treatment should be directed towards correcting that disorder too.
- Benditt, D. G., N. Samniah, et al. (2005). "Effect of cough on heart rate and blood pressure in patients with "cough syncope"." Heart Rhythm 2(8): 807-13.
- Chao, A. C., R. T. Lin, et al. (2007). "Mechanisms of cough syncope as evaluated by valsalva maneuver." Kaohsiung J Med Sci 23(2): 55-62.
Choi, Y. S., J. J. Kim, et al. (1989). "Cough syncope caused by sinus arrest in a patient with sick sinus syndrome." Pacing Clin Electrophysiol 12(6): 883-6.
- Dhar, R., R. J. Duke, et al. (2003). "Cough syncope from constrictive pericarditis: a case report." Can J Cardiol 19(3): 295-6.
- Funakawa, I., & Terao, A. (1998). Intractable hiccups and syncope in multiple sclerosis. Acta Neurol Scand, 98(2), 136-139.
- Gelisse, P. and P. Genton (2008). "Cough syncope misinterpreted as epileptic seizure." Epileptic Disord 10(3): 223-4.
- Ireland, P. D., D. Mickelsen, et al. (1996). "Evaluation of the autonomic cardiovascular response in Arnold-Chiari deformities and cough syncope syndrome." Arch Neurol 53(6): 526-31.
- Mattle, H. P., A. C. Nirkko, et al. (1995). "Transient cerebral circulatory arrest coincides with fainting in cough syncope." Neurology 45(3 Pt 1): 498-501.
- Sakakibara, R., Mori, M., Fukutake, T., Kita, K., & Hattori, T. (1997). Orthostatic hypotension in a case with multiple sclerosis. Clin Auton Res, 7(3), 163-165.
- Shibazaki, K., Kurokawa, K., Murakami, T., & Sunada, Y. (2006). [Medullary tegmentum lesion in a patients having intractable hiccups, nausea, and syncope]. Rinsho Shinkeigaku, 46(5), 339-341.
- Sueyoshi, S., Shin, B., & Nakashima, T. (2013). [Repeated syncope episodes caused by intractable hiccups; a case report]. Nihon Jibiinkoka Gakkai Kaiho, 116(10), 1120-1125.
- Takazawa, T., Ikeda, K., Kano, O., Kabuki, T., Kawabe, K., & Iwasaki, Y. (2014). A case of sinus arrest and post-hiccup cough syncope in medullary infarction. J Stroke Cerebrovasc Dis, 23(3), 566-571. doi:10.1016/j.jstrokecerebrovasdis.2013.04.016
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