Functional heartburn (FH) is a common disorder that accounts for 30% to 50% of patients with nonerosive reflux disease. The group of patients with FH is heterogeneous and primarily consists of hypersensitive patients and patients with nonacid sensitive esophagus. The mechanisms responsible for pain and clinical characteristics of FH and the optimal therapeutic approach are not fully understood. Because FH patients have a lower symptom response rate to potent antireflux treatment, many proton pump inhibitor (PPI) nonresponders are FH patients. Underlying mechanisms other than acid reflux are likely the cause of symptoms for many FH patients. Patients with FH should be approached therapeutically as patients with gastroesophageal reflux disease and should initially receive antireflux medications. PPIs should be considered early in their management. Pain modulators and visceral analgesics are an appropriate therapeutic approach for PPI nonresponders. Data about the usage of other therapeutic modalities in FH are scarce. Emerging treatment modalities are likely to include novel pain modulators and more effective antireflux medications.