Heartburn and reflux: causes and what helps
Heartburn is a burning behind the breastbone that rises after meals or at night, caused by acid moving from the stomach into the oesophagus. Most cases respond to changes anyone can make and to treatments sold at a pharmacy. This page covers what causes reflux, what actually helps, when a prescription and testing become relevant, and the symptoms that must never be treated as indigestion.
What does reflux feel like?
The classic symptom is a burning discomfort behind the breastbone that moves upwards, often starting after a large meal, when bending forward, or when lying down at night. Many people also describe a sour or bitter taste at the back of the throat as stomach contents rise, sometimes waking them.
Reflux does not always burn. It can present as a persistent dry cough, a hoarse voice in the morning, frequent throat clearing, a feeling of a lump in the throat, or worsening asthma at night. Some people have pain that is uncomfortable rather than burning and put it down to stress.
Occasional heartburn is normal and needs no label. Gastro-oesophageal reflux disease is the term used when symptoms are frequent, persistent, or cause complications such as inflammation of the oesophagus. The distinction matters because frequent symptoms deserve a plan rather than a packet of antacids used indefinitely.
What causes it?
A muscular ring at the lower end of the oesophagus normally keeps stomach contents where they belong. Reflux happens when that barrier relaxes at the wrong time or when pressure inside the abdomen pushes contents past it, and the oesophagus, unlike the stomach, has no protection against acid.
The usual contributors are large or late meals, excess weight around the abdomen, pregnancy, smoking, alcohol, and a hiatus hernia in which part of the stomach slides upwards through the diaphragm. Trigger foods vary between individuals; coffee, chocolate, fatty or fried food, spicy food, citrus, tomato and fizzy drinks are the ones most often identified.
Several medicines relax the barrier or irritate the lining, including anti-inflammatory painkillers such as ibuprofen, some calcium channel blockers, nitrates, bisphosphonates and certain antibiotics. If symptoms started after a new medicine, that connection is worth raising rather than simply adding another treatment on top. Persistent infection with Helicobacter pylori is a different problem that causes ulcers and may need testing.
What helps without a prescription?
Practical changes are more effective than they sound. Eat smaller meals, leave three hours between the last meal and lying down, raise the head of the bed rather than piling up pillows, avoid tight waistbands, stop smoking, and reduce alcohol. Where there is excess weight around the abdomen, losing some of it does more for reflux than any tablet.
At a pharmacy, antacids neutralise acid quickly and suit occasional symptoms, while alginate preparations form a raft over the stomach contents and are typically taken after meals and at bedtime. A short course of a low-dose proton pump inhibitor is also available from a pharmacist for frequent heartburn.
Keep a brief record of what preceded the symptoms for a couple of weeks; it usually identifies personal triggers faster than eliminating whole food groups. Self-treatment is appropriate for short-lived, typical heartburn. It is not appropriate for symptoms that persist beyond a couple of weeks of treatment, symptoms that keep coming back the moment treatment stops, or any of the warning features below.
When is a prescription or a test needed?
Prescription-strength acid suppression is considered when symptoms are frequent, when over-the-counter treatment has not controlled them, or when inflammation of the oesophagus has been confirmed. Proton pump inhibitors such as omeprazole, lansoprazole, esomeprazole and pantoprazole are the mainstay, taken before food, usually for a defined course and then reviewed.
Testing for Helicobacter pylori, by breath or stool test, is offered where ulcer disease is suspected. If the test is positive, treatment is a combination of acid suppression and antibiotics for a defined period, prescribed by a doctor. That course must be completed as directed, because a partially treated infection persists and becomes harder to clear.
Endoscopy is arranged when warning features are present, when symptoms persist despite treatment, or when the picture is unclear. Long-term acid suppression is neither forbidden nor trivial: it is appropriate for some conditions, but it should be reviewed periodically with an attempt to step down to the lowest effective dose, because prolonged use has recognised effects on absorption of vitamin B12, magnesium and calcium.
When do I need medical help without delay?
Call 112 or 999 if chest pain is crushing or pressing, spreads to the jaw, neck, back or arm, or comes with sweating, nausea, breathlessness or light-headedness. A heart attack is regularly mistaken for indigestion, and antacids appearing to help proves nothing. Treat new or unusual chest pain as cardiac until a doctor says otherwise.
Go to an Emergency Department if you vomit blood or material that looks like coffee grounds, if your stools are black and tarry, if you have severe abdominal pain, or if you feel faint with any of these. Those indicate bleeding in the upper digestive tract.
Arrange an assessment promptly, without waiting to see whether treatment helps, for difficulty swallowing or food sticking, unintentional weight loss, persistent vomiting, a lump in the abdomen, symptoms that keep waking you, anaemia found on a blood test, or new persistent indigestion beginning in later life. These are the features that lead to endoscopy rather than to another prescription.
Reflux in pregnancy
Heartburn is very common in pregnancy, particularly in the later months, because hormonal changes relax the muscular barrier and the growing uterus raises pressure in the abdomen. It is unpleasant rather than dangerous, and it usually settles after delivery.
First measures are the same as for anyone else: smaller and earlier meals, avoiding personal triggers, and raising the head of the bed. Where that is not enough, treatment options in pregnancy are well established, and antacid and alginate preparations are commonly used. A pharmacist can advise which products are suitable, and a midwife or GP can review if symptoms are severe.
Severe upper abdominal pain in pregnancy is not automatically reflux. Pain below the ribs on the right side, particularly with headache, visual disturbance, swelling or feeling generally unwell, can indicate pre-eclampsia and needs urgent maternity assessment on the same day rather than an antacid.
Long-term reflux: what to keep an eye on
Reflux that continues for years causes inflammation, and in a minority of people the lining of the lower oesophagus changes in a condition called Barrett's oesophagus. It causes no symptoms of its own, is found at endoscopy, and where it is diagnosed a surveillance plan is agreed with a specialist. Most people with reflux never develop it.
That is the argument for treating persistent reflux properly rather than living on antacids for years. It is also the argument for taking warning features seriously the first time they appear, particularly difficulty swallowing and unexplained weight loss.
Once symptoms are controlled, discuss stepping treatment down rather than continuing indefinitely by default: the lowest dose that keeps you comfortable, or treatment taken only when needed, suits many people. Stopping a proton pump inhibitor abruptly after long use can cause a temporary rebound of acid symptoms, so reducing gradually with medical advice is easier than stopping outright.
How do I know whether it is heartburn or my heart?
You often cannot tell from the sensation alone, which is why chest pain that is new, severe or different from your usual pattern, or that comes with sweating, breathlessness, nausea or pain spreading to the jaw or arm, is treated as cardiac until assessed. Call 112 or 999 rather than waiting to see whether an antacid helps.
Can I take a proton pump inhibitor long term?
Sometimes it is the right treatment, for example after confirmed inflammation of the oesophagus. It should be reviewed periodically, kept at the lowest effective dose, and reduced gradually rather than stopped abruptly, because long-term use affects absorption of vitamin B12, magnesium and calcium.
Does milk help heartburn?
It can soothe briefly, but the fat and protein stimulate acid production afterwards, so symptoms often return worse. An antacid or alginate from a pharmacy is more reliable, and eating earlier in the evening does more than any single food.
Do I need to be tested for Helicobacter pylori?
Testing is used where ulcer disease is suspected or symptoms persist, not for everyone with occasional heartburn. If the test is positive, treatment combines acid suppression with antibiotics for a defined course, prescribed and supervised by a doctor.
Which foods should I cut out?
Triggers are individual. Rather than eliminating whole food groups, keep a short record for a fortnight and cut out what your own record identifies. Meal size and timing usually matter more than which foods are on the plate.