What are the treatment options for intractable hiccups?

Treatment Options for Intractable Hiccups

Chlorpromazine is the first-line pharmacological treatment for intractable hiccups, administered at 25-50 mg intramuscularly or intravenously for rapid relief. 1

Understanding Hiccups

Hiccups (singultus) are sudden contractions of the diaphragm and intercostal muscles followed by laryngeal closure, producing the characteristic "hic" sound. While most hiccup episodes are self-limiting, they are classified as:

• Persistent: lasting longer than 48 hours
• Intractable: lasting longer than 2 months

Hiccups result from irritation of a reflex arc involving phrenic, vagal, and sympathetic pathways with central midbrain modulation. 2

Treatment Algorithm for Intractable Hiccups

First-Line Approaches:

1. Non-pharmacological interventions:

   • Breathing techniques (breath holding, Valsalva maneuver)
   • Pharyngeal stimulation (drinking cold water, gargling)
   • Carotid sinus massage

2. Pharmacological therapy:

   • Chlorpromazine: FDA-approved for intractable hiccups 1
     • Dosing: 25-50 mg IM or slow IV infusion (25-50 mg in 500-1000 mL saline)
     • Monitor blood pressure closely during IV administration
     • For oral maintenance: 25-50 mg three times daily

Second-Line Pharmacological Options:

If chlorpromazine is ineffective or contraindicated:

• Metoclopramide: Prokinetic agent that may help with hiccups of gastrointestinal origin 3
• Baclofen: GABA-B receptor agonist that reduces neuronal excitability 2, 4
• Gabapentin: Effective for neuropathic causes of hiccups 2, 4
• Lidocaine: For refractory cases, administered intravenously with cardiac monitoring 2

Interventional Approaches for Refractory Cases:

For hiccups that fail to respond to pharmacotherapy:

1. Nerve blockade:

   • Phrenic nerve block or crushing (caution: results in diaphragmatic paralysis) 4

2. Neurostimulation:

   • Vagus nerve stimulation has shown promise in case reports 4

3. Surgical interventions:

   • Microvascular decompression of the vagus nerve when neurovascular compression is identified 5
   • Consider when imaging shows compression of the dorsal medulla oblongata 6

Important Clinical Considerations

• Identify and treat underlying causes: Hiccups may result from central causes (stroke, space-occupying lesions) or peripheral causes (GERD, myocardial ischemia, herpes infection) 2

• Medication-induced hiccups: Consider drug-induced etiology (steroids, anesthetics, anti-parkinsonian medications, chemotherapy) 2

• Monitor for complications: Prolonged hiccups can lead to:

  • Weight loss
  • Exhaustion
  • Sleep disturbance
  • Wound dehiscence
  • Aspiration

• Alternative therapies: Acupuncture and hypnosis have shown some success in case reports but lack robust evidence 3, 4

Pitfalls to Avoid

• Failure to investigate underlying causes: Intractable hiccups often indicate serious underlying pathology that requires diagnosis and treatment

• Overlooking drug interactions: Chlorpromazine may cause hypotension, especially in elderly or debilitated patients; administer with caution and monitor vital signs 1

• Delayed escalation of therapy: For truly intractable hiccups causing significant morbidity, don't delay progression to more advanced interventions if first-line treatments fail

• Neglecting psychological impact: Persistent hiccups can cause significant psychological distress, depression, and social isolation that may require specific management