Treatment of Hiccups
Chlorpromazine (25-50 mg orally three to four times daily) is the most effective first-line treatment for persistent or intractable hiccups, as it is the only FDA-approved medication for this condition. 1
Understanding Hiccups
Hiccups (singultus) are sudden, involuntary contractions of the diaphragm and intercostal muscles followed by immediate laryngeal closure, producing the characteristic "hic" sound. They can be classified as:
- Acute: Self-limited episodes lasting less than 48 hours
- Persistent: Episodes lasting more than 48 hours
- Intractable: Episodes lasting more than 2 months
Treatment Algorithm
Step 1: Non-Pharmacological Approaches (for acute hiccups)
- Hiccup Relief using Active Prolonged Inspiration (HAPI) technique: Have the patient inspire maximally, then continue attempting to inspire with an open glottis for 30 seconds, followed by slow expiration 2
- Physical maneuvers that stimulate the pharynx or disrupt diaphragmatic rhythm:
- Holding breath
- Breathing into a paper bag (creates transient hypercapnia)
- Drinking water from the opposite side of a glass
- Swallowing dry granulated sugar
- Gentle pressure on eyeballs (vagal stimulation)
Step 2: First-Line Pharmacological Treatment (for persistent hiccups)
- Chlorpromazine 25-50 mg orally three to four times daily 1
- Mechanism: Dopamine antagonist that affects the central hiccup center
- FDA-approved specifically for hiccups
- Monitor for potential side effects: hypotension, sedation, extrapyramidal symptoms
Step 3: Alternative Pharmacological Options (if chlorpromazine fails)
- Baclofen: 5-25 mg three times daily
- Gabapentin: 300-900 mg three times daily
- Metoclopramide: 10 mg three to four times daily
- Valproic acid: 250-500 mg twice daily
Special Considerations
Addressing Underlying Causes
Persistent hiccups often have underlying causes that should be addressed:
- Central causes: stroke, brain tumors, traumatic brain injury
- Peripheral causes: gastroesophageal reflux disease (GERD), myocardial ischemia, phrenic nerve irritation
- Metabolic causes: uremia, electrolyte disturbances
- Medication-induced: steroids, benzodiazepines, chemotherapy agents
Refractory Cases
For hiccups that don't respond to conventional treatment:
- Nerve blocks (phrenic nerve)
- Acupuncture
- Surgical intervention (in extreme cases)
Pitfalls and Caveats
- Don't underestimate the impact of persistent hiccups on quality of life - they can lead to exhaustion, weight loss, dehydration, and psychological distress
- Always consider drug interactions when prescribing chlorpromazine, especially in elderly patients or those on multiple medications
- Chlorpromazine can cause QT prolongation - use with caution in patients with cardiac conditions
- For patients with renal or hepatic impairment, dose adjustment of medications may be necessary
- Persistent hiccups can be a symptom of serious underlying pathology - thorough evaluation is warranted if hiccups persist beyond 48 hours
By following this structured approach to hiccup management, most cases can be effectively treated, improving patient comfort and quality of life.