What is the treatment for persistent hiccups?

Treatment for Persistent Hiccups

Chlorpromazine is the first-line pharmacological treatment for persistent hiccups, with a recommended dosage of 25-50 mg orally three to four times daily, or administered intramuscularly or intravenously if oral therapy is ineffective. 1, 2

Definition and Classification

Hiccups (singultus) are involuntary contractions of the diaphragm followed by sudden closure of the glottis, producing the characteristic "hic" sound. They are classified based on duration:

• Acute: Less than 48 hours
• Persistent: More than 48 hours but less than 2 months
• Intractable: More than 2 months

First-Line Treatment

Chlorpromazine

• Dosage:

  • Oral: 25-50 mg three to four times daily 1
  • Parenteral: 25-50 mg IM if symptoms persist for 2-3 days after trial with oral therapy 2
  • IV: 25-50 mg in 500-1000 mL saline as slow infusion (for intractable cases) 2

• Monitoring:

  • Monitor for hypotension (keep patient lying down for at least 30 minutes after injection)
  • Watch for QT prolongation, especially if combined with other QT-prolonging medications
  • Be alert for extrapyramidal symptoms and sedation

Alternative Pharmacological Options

If chlorpromazine is ineffective or contraindicated, consider:

1. Metoclopramide: 10-20 mg orally or IV every 4-6 hours 3

   • Particularly useful when hiccups are related to gastric distention or GERD

2. Baclofen: 5-10 mg three times daily

   • Effective for persistent hiccups with fewer side effects than chlorpromazine 4

3. Gabapentin: Starting at 300 mg daily, increasing as needed

   • Well-tolerated alternative, particularly in rehabilitation patients 5

4. Haloperidol: 0.5-2 mg orally or IV every 4-6 hours 3

   • Alternative antipsychotic with similar mechanism to chlorpromazine

5. Olanzapine: 5-10 mg daily 3

   • Category 1 evidence for breakthrough treatment in chemotherapy-induced nausea/vomiting

Non-Pharmacological Approaches

Several physical maneuvers may terminate hiccups:

• Stimulation of the pharynx
• Interruption of normal respiratory patterns (breath holding)
• Vagal stimulation techniques (drinking cold water, Valsalva maneuver)
• Phrenic nerve blockade (for intractable cases)

Addressing Underlying Causes

Persistent hiccups often have an underlying cause that should be identified and treated:

1. Gastroesophageal reflux disease (GERD)

   • Add H2 blockers or proton pump inhibitors 3
   • Consider prokinetic agents

2. Central nervous system disorders

   • Evaluate for stroke, space-occupying lesions, or other neurological conditions

3. Metabolic disorders

   • Check electrolytes, renal function

4. Thoracic disorders

   • Evaluate for myocardial ischemia, pericarditis, or diaphragmatic irritation

Treatment Algorithm

1. Initial approach: Try physical maneuvers for acute hiccups
2. For persistent hiccups: Start chlorpromazine 25-50 mg orally three times daily
3. If ineffective after 24-48 hours: Consider parenteral chlorpromazine or alternative agent
4. If still unresolved: Consider combination therapy or nerve blockade

Common Pitfalls

• Underestimating impact: Persistent hiccups can lead to significant morbidity including weight loss, fatigue, and depression
• Missing underlying causes: Always evaluate for and treat underlying conditions
• Inadequate dosing: Ensure adequate dosing and duration before switching therapies
• QT prolongation risk: Be cautious when combining chlorpromazine with other QT-prolonging medications 3
• Sedation concerns: Monitor for excessive sedation, especially in elderly patients

While chlorpromazine remains the only FDA-approved medication specifically for hiccups, evidence suggests that other agents like baclofen and gabapentin may be equally effective with potentially fewer side effects in certain patient populations 6, 5.