About the Rome IV Criteria for Functional Heartburn
Heartburn that does not respond to acid suppression is usually not an acid problem, and functional heartburn is the diagnosis for that situation. Rome IV requires burning retrosternal discomfort at least twice a week, no symptom relief despite optimal antisecretory therapy, no evidence that reflux disease or eosinophilic oesophagitis is responsible, and no major oesophageal motor disorder — fulfilled over three months with onset at least six months ago. The distinction from reflux hypersensitivity is one test result: both have normal acid exposure, but in functional heartburn the symptoms do not track reflux events.
Formula
Functional heartburn = ALL of:
burning retrosternal discomfort or pain
AND no symptom relief despite optimal antisecretory therapy
AND no evidence that reflux disease or eosinophilic oesophagitis is the cause
AND no major oesophageal motor disorder
AND criteria fulfilled for the last 3 months, onset >= 6 months ago,
at least twice a week- Optimal antisecretory therapy
- Double-dose proton pump inhibitor taken correctly. Failure of adequately-dosed therapy is a criterion, so establishing adherence and timing comes before the diagnosis.
- No evidence reflux is the cause
- Requires reflux monitoring off therapy showing neither abnormal acid exposure nor a positive symptom-reflux association — the latter is what would make it reflux hypersensitivity.
- At least twice a week
- The frequency threshold. Functional heartburn and reflux hypersensitivity share it; chest pain, globus and dysphagia use once a week.
- Failure of optimal antisecretory therapy is a criterion, not an outcome — it must be established before the diagnosis, not after it.
- Reflux monitoring off therapy is what separates this from reflux hypersensitivity: functional heartburn has neither abnormal acid exposure nor a positive symptom-reflux association.
Interpreting the result
Meeting the criteria is a positive diagnosis, and it should change the prescription rather than simply close the file. The immediate implication is to stop escalating acid suppression: continuing to increase a proton pump inhibitor in a patient with documented normal acid exposure and a negative symptom association treats a mechanism that testing has excluded. The evidence-based alternative is a neuromodulator — tricyclic antidepressants, SSRIs or trazodone at doses well below antidepressant range, prescribed for their effect on visceral pain processing and explained to the patient in those terms, since a patient told they are being given an antidepressant for heartburn will usually stop it. Failure to meet criteria is more often a gap in investigation than an absent diagnosis, and the missing piece is nearly always reflux monitoring performed off therapy. One caveat worth holding: functional heartburn and reflux disease can coexist, and a patient with proven GORD who has residual symptoms after their acid exposure has normalised may have both.
| Score | Band | What it means | Action |
|---|---|---|---|
| All criteria met | Functional heartburn | Heartburn with normal acid exposure and no symptom-reflux association — a disorder of oesophageal hypersensitivity rather than of acid | Stop escalating acid suppression; start a neuromodulator and consider oesophageal-directed behavioural therapy |
| Any criterion unmet | Criteria not met | Most often because reflux monitoring off therapy has not been done, rather than because the diagnosis is wrong | Complete the outstanding investigation. If symptoms do track reflux events, the diagnosis is reflux hypersensitivity |
What the Functional Heartburn needs (5 inputs)
- Timing and frequency
- Criteria fulfilled for the last three months, symptom onset at least six months before diagnosis, occurring at least twice a week. Twice weekly is a higher bar than the once-weekly threshold used for functional chest pain, globus and functional dysphagia.
- Burning retrosternal discomfort or pain
- The symptom is ordinary heartburn. Nothing about how it feels distinguishes functional heartburn from reflux disease — that separation is made entirely by testing.
- No symptom relief despite optimal antisecretory therapy
- Optimal means an adequate dose for an adequate duration, taken 30 to 60 minutes before meals, with adherence confirmed. Apparent PPI failure is very often a timing problem, and taking the drug after food rather than before is the single commonest reason a trial fails.
- No evidence that reflux disease or eosinophilic oesophagitis is the cause
- Requires normal endoscopy with oesophageal biopsies, and physiological acid exposure on pH or pH-impedance monitoring with no symptom-reflux association. Biopsies are not optional — eosinophilic oesophagitis frequently looks normal.
- No major oesophageal motor disorder
- Achalasia, EGJ outflow obstruction, distal oesophageal spasm, jackhammer oesophagus or absent contractility on high-resolution manometry.
What it returns
- Criteria met or not met
- All five requirements including the timing rule must be satisfied. There is no partial result — Rome IV disorders are conjunctive.
- Which criteria remain outstanding
- Named explicitly, because in practice the unmet item is usually a test that has not been done rather than a feature the patient lacks.
How it is calculated
Rome IV split what Rome III had treated as one entity. Under the older framework, heartburn with normal acid exposure was a single category, which grouped patients whose symptoms coincided with reflux events alongside those whose did not — and those two groups behave differently in response to treatment. Rome IV separated them, keeping the name functional heartburn for the group with no symptom-reflux association and creating reflux hypersensitivity for the group with one. The logic is mechanistic: if reflux events reliably provoke symptoms, some reflux-directed treatment may still help, whereas if they do not, the symptom is being generated by oesophageal hypersensitivity and central pain processing rather than by the refluxate at all. Everything else in the criteria is exclusion, and the exclusions are deliberately demanding because the conditions being ruled out are common and treatable.
Facts & figures
| Acid exposure | Symptom-reflux association | Response to PPI | |
|---|---|---|---|
| GORD | Abnormal | Usually positive | Usually responds |
| Reflux hypersensitivity | Normal | Positive | Partial response is common and compatible |
| Functional heartburn | Normal | Negative | No response — this is a diagnostic criterion |
The three are separated by pH or pH-impedance monitoring, not by how the heartburn feels. A patient cannot be sorted into one of these boxes on history alone, which is why the criteria require the testing rather than suggesting it.
| Cause | What to check |
|---|---|
| Wrong timing | Proton pump inhibitors need taking 30–60 minutes before a meal. Taken with or after food, efficacy drops substantially |
| Adherence | Ask directly about missed doses and about stopping when better |
| Inadequate duration | An adequate trial is 8 weeks, not 2 |
| The symptom is not heartburn | Regurgitation, chest pain and dyspepsia respond less well to acid suppression than heartburn does |
| Eosinophilic oesophagitis | Biopsies. It can present with heartburn and a normal-looking oesophagus |
Rome IV requires 'optimal' antisecretory therapy for a reason. Diagnosing functional heartburn in a patient who has never taken their PPI before meals attributes a dosing failure to the brain-gut axis.
Evidence
Derivation — Rome Foundation, oesophageal disorders committee
2016Consensus criteria produced by the Rome IV oesophageal disorders committee and published in Gastroenterology in 2016, revising Rome III. Developed by expert committee with systematic literature review rather than fitted to a cohort, which is the standard method for symptom-based functional definitions where no biomarker exists.
The substantive change from Rome III was separating reflux hypersensitivity out of what had been a single functional heartburn category, on the basis that the presence or absence of a symptom-reflux association predicts response to reflux-directed treatment.
Reflux diagnostic framework — Lyon Consensus 2.0
2024International consensus updating the criteria for a conclusive diagnosis of gastro-oesophageal reflux disease using endoscopy, reflux monitoring and adjunctive metrics.
Defines the acid exposure thresholds and the adjunctive metrics that determine whether reflux disease is present, which is what the Rome IV exclusion depends on in practice.
Guideline adoption — ACG 2022
2022American College of Gastroenterology clinical guideline for the diagnosis and management of gastro-oesophageal reflux disease.
Addresses the refractory-heartburn pathway, recommending reflux monitoring off therapy to distinguish functional heartburn and reflux hypersensitivity from persistent reflux disease before escalating treatment or considering surgery.
How it compares
Functional Heartburn vs Reflux hypersensitivity
One test result separates them — both have normal acid exposure, but reflux hypersensitivity has symptoms that track reflux events and functional heartburn does not.
This is the distinction Rome IV created, and it is not academic. In reflux hypersensitivity, reflux events demonstrably provoke symptoms, so acid suppression may produce partial benefit and continuing it is reasonable. In functional heartburn there is no such association, and continued acid suppression has nothing to act on. Both are diagnosed on pH or pH-impedance monitoring with symptom association analysis, and neither can be distinguished from the other on how the heartburn feels, how severe it is, or how long it has been present. If the symptom association analysis was not performed, the two cannot be told apart and neither diagnosis should be recorded.
Functional Heartburn vs Gastro-oesophageal reflux disease
GORD has abnormal acid exposure; functional heartburn has normal acid exposure and no symptom association, and the two need opposite treatment strategies.
The symptom is the same, which is why the separation requires testing. In GORD, escalating acid suppression and — where appropriate — anti-reflux surgery are rational, because there is excess acid exposure to reduce. In functional heartburn both are futile: acid exposure is already physiological. The Lyon Consensus defines where the boundary sits on reflux monitoring, and the ACG guideline routes refractory heartburn through that testing before escalation precisely so this distinction gets made rather than assumed. The practical harm of missing it is years of unnecessary therapy and, occasionally, an operation that cannot work.
Functional Heartburn vs Functional chest pain
Different symptoms, mutually exclusive criteria — functional chest pain requires the absence of heartburn, so a patient cannot meet both sets.
Rome IV's oesophageal disorders are defined so that they do not overlap. Functional chest pain explicitly requires the absence of associated oesophageal symptoms including heartburn, which means a patient with burning retrosternal discomfort is being assessed for functional heartburn or reflux hypersensitivity rather than for chest pain. The exclusions and the testing pathway are otherwise very similar, and both are treated with neuromodulators, so the practical consequence of picking the wrong label is small — but recording both is a scoring error rather than a description of complex disease.
Pearls & pitfalls
- Three of the four criteria require test results. This diagnosis cannot be made on history, and applying it to a patient who has not had reflux monitoring is applying it prematurely.
- Reflux monitoring should be off therapy when the question is whether reflux disease exists at all. Testing on treatment answers a different question.
- 'Optimal antisecretory therapy' means before meals. A patient taking their proton pump inhibitor after breakfast has not had an adequate trial, and diagnosing functional heartburn on that basis attributes a dosing error to the brain-gut axis.
- Biopsies are mandatory. Eosinophilic oesophagitis can present with heartburn and a completely normal-looking oesophagus, and it is specifically treatable.
- The difference from reflux hypersensitivity is the symptom-reflux association and nothing else. Both have normal acid exposure; only one has symptoms that track reflux events.
- Functional heartburn and GORD can coexist. A patient with proven reflux disease whose acid exposure has normalised on treatment but whose symptoms persist may have both, and the label is not mutually exclusive in that sequence.
- Twice a week is the frequency threshold here, not once — it is stricter than functional chest pain, globus and functional dysphagia.
- Do not offer fundoplication. A patient with normal acid exposure and no symptom association has no reflux for surgery to correct, and outcomes in this group are poor.
- Explain the neuromodulator properly. A patient told they are being prescribed an antidepressant for heartburn will usually not take it; framed as a drug that turns down oesophageal nerve sensitivity, they usually will.
Critical actions
- Confirm the proton pump inhibitor trial was genuinely optimal — correct dose, 8 weeks, taken before meals, adherence checked — before accepting non-response.
- Perform endoscopy with oesophageal biopsies; the biopsies exclude eosinophilic oesophagitis, which a normal appearance does not.
- Arrange pH or pH-impedance monitoring off therapy, with symptom association analysis, since that single result separates the three heartburn phenotypes.
- Obtain high-resolution manometry to exclude a major motor disorder.
- Once criteria are met, stop escalating acid suppression rather than continuing it indefinitely alongside the new treatment.
- Start a neuromodulator at low dose and explain its mechanism in terms of nerve sensitivity, not mood.
- Consider oesophageal-directed hypnotherapy or cognitive behavioural therapy, both of which have trial evidence in functional oesophageal disorders.
- Do not refer for anti-reflux surgery.
Why this score exists
The committee's stated reason for creating reflux hypersensitivity as a separate disorder was that the old functional heartburn category was doing two incompatible jobs. It contained patients in whom reflux events demonstrably provoked symptoms and patients in whom they demonstrably did not, and those groups respond differently to acid suppression and to anti-reflux surgery. Keeping them together meant trial populations were heterogeneous and clinical advice had to be hedged. The split also carried a message about anti-reflux surgery: a patient with normal acid exposure and no symptom association has, by definition, no reflux for a fundoplication to correct, and the committee was explicit that identifying this group matters partly to keep them out of theatre. The demanding exclusions reflect the same instinct — the criteria are written to be difficult to satisfy carelessly.
About the creator
First author, Rome IV oesophageal disorders committee
Chaired the committee that wrote the Rome IV criteria for the functional oesophageal disorders.
Co-author; much of the underlying functional heartburn literature
Contributed the work distinguishing functional heartburn from hypersensitive oesophagus that the Rome IV split rests on.
Co-author; lead author of the Lyon Consensus
Co-authored the Rome IV chapter and led the Lyon Consensus that defines the reflux thresholds these criteria exclude against.
Limitations
- Requires reflux monitoring and manometry, so the diagnosis is unavailable in settings without access to oesophageal physiology testing.
- Symptom association analysis depends on the patient recording symptoms accurately during the study, and a day with few or no symptoms makes the association uninterpretable.
- Acid exposure varies day to day, so a single monitoring study can misclassify a patient near the threshold.
- 'Optimal antisecretory therapy' is not precisely defined in the criteria, leaving room for a diagnosis to rest on an inadequate trial.
- Consensus-derived, so it has no sensitivity or specificity against an objective reference standard — none exists.
- The boundary with reflux hypersensitivity depends on symptom association indices whose thresholds are themselves debated.
- Says nothing about severity or about the substantial psychological comorbidity that accompanies these disorders and often needs addressing alongside.
- Developed largely in Western populations, and heartburn reporting varies culturally.
If you are the patient
Functional heartburn means you get the burning feeling of heartburn, but tests show your oesophagus is not being exposed to too much acid, and the burning does not happen at the moments when acid does come up. It is a real condition and a real explanation — not a case of nothing being found. What is happening is that the nerves in your oesophagus are sending pain signals in response to normal, everyday sensations that most people simply do not notice. That is why acid-reducing tablets do not help: there is no excess acid to reduce. The treatments that do work are medicines that turn down the sensitivity of those nerves. These are often the same drugs used as antidepressants, but here they are given at much lower doses and for a completely different purpose — your doctor is treating nerve sensitivity, not mood. Talking therapies and a form of hypnotherapy aimed specifically at the gullet also have good evidence. Two things are worth knowing. If you are still on strong acid-reducing tablets, your doctor may well suggest stopping them, and that is not giving up on you — it is stopping a treatment the tests have shown cannot work. And surgery for reflux is not helpful in this condition, because there is no excess reflux for an operation to fix.
Frequently asked questions
What are the Rome IV criteria for functional heartburn?#
Burning retrosternal discomfort or pain; no symptom relief despite optimal antisecretory therapy; no evidence that reflux disease or eosinophilic oesophagitis is the cause; and no major oesophageal motor disorder. All must be fulfilled for the last three months, with symptom onset at least six months before diagnosis, occurring at least twice a week.
What is the difference between functional heartburn and reflux hypersensitivity?#
The symptom-reflux association. Both have normal acid exposure on pH or pH-impedance monitoring. In reflux hypersensitivity the symptoms track reflux events, so some response to acid suppression is expected and compatible with the diagnosis. In functional heartburn there is no such association, and non-response to acid suppression is a diagnostic requirement rather than a treatment failure.
Why do proton pump inhibitors not work in functional heartburn?#
Because there is no excess acid to suppress. Acid exposure is physiological by definition in this diagnosis, and reflux events do not provoke the symptoms. The heartburn is generated by oesophageal hypersensitivity and central pain processing, which acid suppression does not act on. Continuing to escalate the dose treats a mechanism the testing has already excluded.
Can you have functional heartburn and GORD at the same time?#
Yes, in sequence. A patient with proven reflux disease whose acid exposure has normalised on treatment but whose heartburn persists may have a functional component on top. The labels are not mutually exclusive over time, and this overlap is one reason repeat reflux monitoring on therapy is sometimes useful in a patient whose original diagnosis was clearly GORD.
What treatment works for functional heartburn?#
Neuromodulators — tricyclic antidepressants, SSRIs or trazodone at low, pain-modulating doses — are the mainstay, alongside oesophageal-directed hypnotherapy or cognitive behavioural therapy. Explaining the mechanism matters as much as the prescription: patients told they are being given an antidepressant for heartburn usually stop taking it, while patients told it reduces nerve sensitivity usually continue.
Should someone with functional heartburn have anti-reflux surgery?#
No. Fundoplication corrects excess reflux, and a patient meeting these criteria has normal acid exposure and no symptom-reflux association — there is nothing for the operation to correct. Outcomes in this group are poor, and one of the stated reasons Rome IV separated these phenotypes was to identify patients who should not be referred for surgery.
How often do symptoms have to occur to meet the criteria?#
At least twice a week. That is stricter than the once-weekly threshold Rome IV applies to functional chest pain, globus and functional dysphagia, and it is shared with reflux hypersensitivity.
Do you need a pH study to diagnose functional heartburn?#
Yes. Three of the four criteria depend on test results, and reflux monitoring — ideally off therapy, with symptom association analysis — is the one that carries the diagnosis. Without it, functional heartburn cannot be distinguished from reflux hypersensitivity or from ongoing reflux disease, and the diagnosis should not be recorded.
References
Original / primary reference
Reflux diagnostic framework
Clinical practice guidelines
- Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022;117(1):27-56.
- Yadlapati R, Kahrilas PJ, Fox MR, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0. Neurogastroenterol Motil. 2021;33(1):e14058 (defines the major motor disorders excluded).