Baclofen for Hiccups
Baclofen can be used for persistent hiccups, particularly those lasting >48 hours, with a typical dose of 10 mg orally three times daily for 5 days, though recent evidence shows it provides benefit in only about 35% of patients overall.
Evidence Quality and Efficacy
The evidence for baclofen in hiccups is mixed but represents the best available data among pharmacologic options:
A 2024 large multisite study 1 found baclofen provided hiccup palliation in only 35% of patients (95% CI: 30-41%), falling short of the study's 75% threshold for true efficacy. However, baclofen appeared more effective for chronic hiccups (>48 hours duration) with an OR of 0.51 for benefit (p=0.02).
A 2014 randomized, double-blind, placebo-controlled trial 2 in stroke patients showed significantly higher cessation rates with baclofen versus placebo (RR 7.00; 95% CI 1.91-25.62; p=0.003), though this was a small study (n=30).
Systematic reviews 3, 4 identify baclofen and gabapentin as having the strongest evidence base, with baclofen supported by small randomized controlled trials—more than most other agents for hiccups.
Dosing Protocol
Standard regimen:
- 10 mg orally three times daily 1, 2
- Duration: 5 days initially 2
- Can continue if effective; reassess if no response after 5 days
The FDA label 5 indicates baclofen is approved as a muscle relaxant for spasticity, not specifically for hiccups, making this an off-label use.
Clinical Decision Algorithm
Duration assessment: Baclofen appears more likely to benefit chronic hiccups (>48 hours) than acute episodes 1
First-line consideration: Based on systematic reviews 3, 4, baclofen or gabapentin should be considered first-line due to better safety profiles than neuroleptics like chlorpromazine (the only FDA-approved agent for hiccups)
Trial period: Give 5 days at standard dosing before declaring treatment failure 2
Alternative if ineffective: Consider gabapentin or metoclopramide, which also have randomized trial support 3, 4
Safety Considerations
Common adverse effects (occurred in 15 patients in the large study 1):
- Drowsiness (most common)
- Dizziness 2
- Generally mild and transient
Critical safety warning 6: Abrupt discontinuation of baclofen, especially after long-term use, can cause severe withdrawal:
- Visual/auditory hallucinations
- Anxiety, agitation, delirium
- Fever, tremors, tachycardia
- Seizures
- Life-threatening with intrathecal baclofen: rhabdomyolysis, multiorgan failure, death
Therefore: If baclofen is continued beyond the initial trial and then discontinued, taper gradually rather than stopping abruptly.
Practical Caveats
- Realistic expectations: With only 35% overall success rate 1, patients should understand baclofen may not work, though odds improve with chronic hiccups
- Underlying cause: Always investigate and treat underlying conditions when possible, as this is most effective 4
- Empiric reflux therapy: Consider a trial of anti-reflux medication as gastroesophageal reflux is a common cause 4
- Sedation risk: Use caution when combining with opioids or other CNS depressants 6