From the Guidelines
Chlorpromazine is the most effective treatment for intractable hiccups, as it has been shown to be effective in treating this condition due to its anticholinergic and antiemetic properties 1. When considering treatment for intractable hiccups, it is essential to identify and address any underlying causes, such as gastroesophageal reflux disease or central nervous system disorders.
- First-line pharmacological treatments include chlorpromazine (25-50 mg intramuscularly or intravenously), which has been used to treat nausea, vomiting, and intractable hiccups 1.
- Other medications that may be effective in treating intractable hiccups include metoclopramide, gabapentin, pregabalin, or valproic acid, although chlorpromazine is the most commonly recommended treatment in the provided evidence 1.
- Non-pharmacological approaches, such as breathing into a paper bag, drinking cold water, swallowing granulated sugar, or stimulating the vagus nerve through techniques like the Valsalva maneuver, may also provide relief for intractable hiccups. It is crucial to monitor patients for medication side effects, particularly when using antipsychotics like chlorpromazine, which can cause QTc prolongation and other cardiac adverse effects 1.
- Patients should be closely observed, and their treatment should be adjusted based on their response to the medication.
- In severe cases where medication is ineffective, nerve blocks targeting the phrenic or vagus nerves may be considered, and in rare instances, surgical intervention might be necessary.
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. If symptoms persist for 2-3 days after trial with oral therapy, give 25 to 50 mg (1-2 mL) IM. Should symptoms persist, use slow IV infusion with patient flat in bed: 25 to 50 mg (1-2 mL) in 500 to 1000 mL of saline.
The treatment for intractable hiccups is chlorpromazine 25 mg to 50 mg orally three to four times a day. If symptoms persist, parenteral therapy may be indicated, with a dose of 25 to 50 mg intramuscularly. In severe cases, a slow IV infusion may be used 2 3.
From the Research
Treatment Options for Intractable Hiccups
- Pharmacologic interventions are often used to treat intractable hiccups, with chlorpromazine being the only drug approved by the US Food and Drug Administration for this purpose 4
- Other pharmacologic treatments that have been proposed for intractable hiccups include amitriptyline, baclofen, gabapentin, haloperidol, metoclopramide, midazolam, nifedipine, nimodipine, orphenadrine, and valproic acid 4
- Baclofen, gabapentin, and metoclopramide have been studied in a prospective manner, and only baclofen and metoclopramide have been studied in randomized controlled trials 4
- Vagus nerve stimulation (VNS) is a novel surgical option for the treatment of intractable hiccups, with some cases reporting significant improvement in symptoms 5
- Phrenic nerve block or crushing is another surgical option for intractable hiccups, and has been shown to be effective in some cases 6
- Ultrasound-guided phrenic nerve block is a minimally invasive procedure that can provide long-term relief from intractable hiccups and associated mediastinal pain 6
Non-Pharmacologic Interventions
- Non-pharmacologic interventions such as drinking cold water, induction of emesis, carotid sinus massage, or Valsalva maneuver may be effective in treating intractable hiccups 5
- Hypnosis, massages, and acupuncture are unconventional therapies that have been used to treat intractable hiccups, although their effectiveness is not well established 5
Considerations for Treatment
- The selection of treatment for intractable hiccups should be individualized, taking into account the patient's underlying comorbidities, etiology of hiccups, and the properties of the drugs or interventions being considered 4
- Intractable hiccups can be associated with significant morbidity and mortality, and prompt treatment is essential to improve the patient's quality of life 7, 8