His ordeal began 24 years ago with an upper respiratory infection. That was when George Gharabeigie began to cough. And cough and cough.

"At first it was sporadic," says the Irvine, California, man, 59. "But then any time I ate ice cream or had a can of soda, I had uncontrollable coughing. If I had a cold, I would cough and cough. Sometimes it was so bad that, at the end of the day, I had a headache and my chest muscles were sore and ached."

Over the years, Gharabeigie saw dozens of doctors about his hacking. But the cough persisted.

Diagnosis

Experts say that's not unusual. Cough accounts for an estimated 23 million doctor visits annually, making it the number 1 reason people see a physician.

But even though a cough can take a physical and personal toll, until recently many doctors failed to see it as anything more than the vestige of a recent illness.

Nor were they sure how best to diagnose and treat it. Now, however, cough specialists are crafting treatment guidelines for chronic cough.

Research is homing in on the many causes, and two cough specialists recently began publishing an online journal (appropriately named Cough) devoted to the topic. Perhaps most visibly, cough clinics are springing up around the nation, typically at university medical centres.
 
"For years there were very few of us working in this area," says Dr Richard S. Irwin, a professor of medicine and nursing at the University of Massachusetts who pioneered the concept of cough clinics. "It seems all of a sudden it's becoming a hot area of research."

But to benefit, patients often must find their way to a doctor who specialises in cough, says Dr Kaiser Lim, a pulmonologist who studies cough at the Mayo Clinic in Rochester.

"Cough crosses so many disciplines," Lim says, "and [nonspecialist] doctors usually aren't cross-trained in allergy, immunology, pulmonary medicine and gastroenterology."

Symptoms

Like with other symptoms for which there can be many causes - pain, for instance - it's not always apparent what is triggering a cough.

The most common causes are allergies, asthma, sinusitis, rhinitis and gastroesophageal reflux disease.
 
Some people may not suspect that their cough is due to asthma, for instance, because they don't have wheezing and shortness of breath.

Likewise, cough can be linked to reflux, in which the contents of the stomach back up into the oesophagus, even without the classic symptoms of heartburn and regurgitation.

Inflammation

In a recent study, Lim found that sinusitis, which is inflammation of the sinuses, was the cause of chronic cough in one-third of the patients studied.

They typically had no other symptoms, such as a runny nose or headache.

"The shame of it is that many of the people had been coughing due to something you could potentially treat," Lim says of his study, which was recently presented at the annual meeting of the American College of Chest Physicians.

The sinusitis patients had been coughing, on average, for 52 months.

Less common triggers of cough include lung cancer, chronic bronchitis (usually linked to smoking) and pertussis, which in the United States has seen a dramatic upswing in cases in the last year.
 
Multiple causes

A cough can even have multiple causes, further complicating treatment, says Dr Brian Levine, medical director of a newly opened Cough Centre in Mission Viejo, California.

And some people seem to simply develop a coughing habit, long after a physiological cause, such as the flu, has disappeared.

"There are many, many causes; that is where the real problem comes in," Levine says. "There are a lot of excellent physicians, but they don't have the time to spend on chronic cough. Patients throw up their hands. They don't know where to turn."
Frustration

Coughs cause frustration with the medical system, anxiety about the cause, anger, sleep problems and relationship problems, Lim found in another study presented last month.

Among patients younger than 65, one-third of the coughers' spouses or roommates had to move out of the bedroom.

"One woman had to quit the choir. A gentleman from Chicago fainted every time he coughed. Another man crashed his car in his neighbour's pool while coughing," Lim says. "People break ribs. They have hernias. Women have urinary incontinence."
 
Lifestyle

Irwin has also studied the lifestyle destruction left in the wake of a chronic cough. Studies show that many people with chronic cough suffer for four years on average before receiving successful treatment.

"Cough can be devastating to a person's quality of life," he says. He's known sufferers to quit school, lose jobs or get divorced because of a persistent, hacking cough.

"That's why we need to get the message out to the public that if the right [doctor] is taking care of you - following cough management protocols that have been developed according to the best available evidence - people have a very good chance of having their cough improved or cured."