Treatment Options for Persistent Hiccups
Chlorpromazine is the first-line pharmacological treatment for persistent hiccups, as it is the only FDA-approved medication for this condition. 1
Understanding Hiccups
Hiccups (singultus) occur due to sudden diaphragmatic and intercostal muscle contractions followed by laryngeal closure, creating the characteristic "hic" sound. They are categorized based on duration:
- Acute: Less than 48 hours
- Persistent: Lasting more than 48 hours
- Intractable: Continuing for more than 2 months
Treatment Algorithm
Step 1: Physical Maneuvers (for acute hiccups)
- Breath holding
- Valsalva maneuver
- Stimulation of the pharynx by drinking water rapidly
- Interruption of normal respiratory patterns
Step 2: Pharmacological Treatment for Persistent/Intractable Hiccups
First-line therapy:
- Chlorpromazine: 25-50 mg IM for immediate relief. If symptoms persist after oral therapy trial, administer 25-50 mg IM. For refractory cases, use slow IV infusion with patient lying flat: 25-50 mg in 500-1000 mL saline (monitor blood pressure closely) 1
Alternative pharmacological options (if chlorpromazine fails or is contraindicated):
- Baclofen: First choice for central causes of hiccups 2
- Metoclopramide: First choice for peripheral causes of hiccups 2
- Gabapentin: Effective for persistent hiccups 3
- Other options:
- Haloperidol
- Amitriptyline
- Nifedipine
- Valproic acid
- Midazolam (particularly useful in terminal illness) 2
Step 3: Interventional Procedures (for refractory cases)
- Vagal nerve block or stimulation
- Phrenic nerve block
- Acupuncture (though evidence is limited) 2
Etiology-Based Approach
Understanding the cause of hiccups can guide treatment selection:
Central Causes
- Stroke
- Space-occupying lesions
- CNS injury
- Treatment of choice: Baclofen 2
Peripheral Causes
- Gastroesophageal reflux disease
- Myocardial ischemia
- Herpes infection
- Tumors along the reflex arc
- Iatrogenic causes (instrumentation)
- Treatment of choice: Metoclopramide 2
Important Considerations
- Medication-induced hiccups: Review the patient's medication list for potential triggers (anti-parkinsonian drugs, anesthetics, steroids, chemotherapy)
- Underlying conditions: Address treatable causes such as gastroesophageal reflux, electrolyte imbalances, or infections
- Monitoring: Watch for side effects of chlorpromazine, particularly hypotension (keep patient lying down for at least 30 minutes after injection) 1
Evidence Limitations
The evidence for hiccup treatments remains limited. A Cochrane review found insufficient evidence to guide treatment with either pharmacological or non-pharmacological interventions 4. Most studies have small sample sizes, lack placebo controls, or have high risk of bias. Despite this limitation, chlorpromazine remains the only FDA-approved medication for hiccups 5.
Emerging Treatments
Some novel approaches showing promise include:
- Oral lidocaine solution (2%) or gel for refractory cases 6
- Combination therapies targeting multiple pathways in the hiccup reflex arc
While the evidence base for hiccup treatment remains suboptimal, a systematic approach starting with chlorpromazine and progressing through alternative agents based on the suspected etiology offers the best chance for symptom relief.