Treatment of Hiccups
Chlorpromazine (25-50 mg orally three to four times daily) is the most effective first-line pharmacological treatment for intractable hiccups. 1
Classification of Hiccups
Hiccups can be categorized based on duration:
- Acute: Less than 48 hours
- Persistent: 48 hours to 2 months
- Intractable: More than 2 months
Treatment Algorithm
Step 1: Non-Pharmacological Approaches (for acute hiccups)
- Breath holding
- Drinking water from the opposite side of a glass
- Stimulation of the uvula/pharynx
- Disruption of diaphragmatic rhythm
- Larson's maneuver: applying pressure between the mandible and mastoid process while performing jaw thrust 2
Step 2: Pharmacological Treatment (for persistent/intractable hiccups)
Based on whether the cause is central or peripheral:
For Central Causes:
For Peripheral Causes:
- Metoclopramide - First-line for peripheral causes 3
- Chlorpromazine - 25-50 mg orally three to four times daily 1
- For severe cases: 25-50 mg IM if symptoms persist for 2-3 days after oral therapy
- For very severe cases: 25-50 mg in 500-1000 mL saline as slow IV infusion (monitor blood pressure closely) 5
Step 3: Interventional Procedures (for refractory cases)
- Nerve blockade (phrenic or vagal)
- Nerve stimulation
- Acupuncture 4
Etiology Assessment
When evaluating persistent hiccups, investigate for underlying causes:
Central Causes:
- Stroke
- Brain tumors
- Traumatic brain injury
Peripheral Causes:
- Gastroesophageal reflux disease (most common)
- Gastric distention
- Myocardial ischemia
- Herpes zoster infection
- Medications (steroids, anesthetics, anti-parkinsonism drugs)
Special Considerations
Palliative Care Setting
- Consider midazolam for terminal illness cases 3
- Focus on improving quality of life as the primary outcome
Medication Selection Pitfalls
- Chlorpromazine may cause hypotension and sedation; use with caution in elderly patients 1
- Monitor for extrapyramidal side effects with prolonged use of chlorpromazine
- Baclofen may cause drowsiness and should be started at low doses
Treatment Efficacy
While many treatments for hiccups are based on anecdotal evidence rather than controlled clinical trials, chlorpromazine has the longest history of documented efficacy for intractable hiccups 6. The FDA specifically approves chlorpromazine for "relief of intractable hiccups" 5, making it the most evidence-supported pharmacological intervention despite the lack of large randomized controlled trials.
For most patients with acute hiccups, non-pharmacological approaches are sufficient, and medical intervention is rarely required as these episodes typically resolve spontaneously within minutes 7.