What is the treatment approach for intractable hiccups (hiccups lasting over 24 hours)?

From the FDA Drug Label

Intractable Hiccups– 25 mg to 50 mg t.i.d. or q.i.d. If symptoms persist for 2 to 3 days, parenteral therapy is indicated. The treatment approach for intractable hiccups (hiccups lasting over 24 hours) is to administer chlorpromazine 25 mg to 50 mg t.i.d. or q.i.d. 1. If symptoms persist for 2 to 3 days, parenteral therapy is indicated.

• Key points:
  • Initial dose: 25 mg to 50 mg
  • Frequency: t.i.d. or q.i.d.
  • Duration: until symptoms are controlled, but if symptoms persist for 2 to 3 days, consider parenteral therapy.

From the Research

The most effective treatment approach for intractable hiccups (lasting over 24 hours) is to identify and address underlying causes, and use first-line pharmacological treatments such as proton pump inhibitors (PPIs), chlorpromazine, metoclopramide, or baclofen, as recommended by the most recent study 2.

Treatment Approach

The treatment of intractable hiccups should begin with a thorough medical history and physical examination to identify underlying causes, such as gastroesophageal reflux disease (GERD), central nervous system disorders, or metabolic abnormalities.

• First-line pharmacological treatment typically includes:
  • PPIs, such as omeprazole or lansoprazole, to treat GERD 2
  • Chlorpromazine (25-50 mg orally or intramuscularly every 6 hours) 3
  • Metoclopramide (10 mg orally or intravenously three times daily) 3, 4
  • Baclofen (5-10 mg orally three times daily, gradually increasing to 15-20 mg three times daily if needed) 3, 4
• Second-line medications include:
  • Gabapentin (starting at 300 mg daily, increasing gradually to 900-1800 mg daily in divided doses) 3
  • Pregabalin (starting at 50 mg three times daily, increasing as needed) 3

Non-Pharmacological Interventions

Non-pharmacological interventions can also be effective, including:

• Breathing techniques (breath holding, breathing into a paper bag)
• Stimulation of the vagus nerve (drinking cold water, gargling)
• Physical maneuvers to interrupt the hiccup reflex These treatments work by either suppressing the hiccup reflex arc, reducing diaphragmatic irritability, or modulating central nervous system pathways involved in hiccup generation.

Refractory Cases

For refractory cases, combination therapy may be necessary, and consultation with specialists in neurology, gastroenterology, or pain management may be required for more advanced interventions such as nerve blocks or surgical approaches 2, 5.