What is the treatment for hiccups (hiccup tx)?

Treatment for Hiccups

For persistent hiccups, chlorpromazine (25-50 mg orally three to four times daily) is the first-line pharmacological treatment, while simple physical maneuvers should be attempted first for brief episodes. 1

Classification of Hiccups

Hiccups can be categorized based on duration:

• Brief/acute: Self-limited episodes lasting minutes to hours
• Persistent: Episodes lasting more than 48 hours but less than 2 months
• Intractable: Episodes lasting longer than 2 months 2

First-Line Approaches for Brief Hiccups

For brief episodes, try these non-pharmacological interventions first:

1. Physical maneuvers that stimulate the pharynx or disrupt respiratory rhythm:
   • Breath holding
   • Drinking water rapidly
   • Swallowing granulated sugar
   • Pulling on the tongue
   • Stimulating the uvula/pharynx
   • Applying pressure between the posterior border of the mandible and mastoid process (similar to Larson's maneuver) 3

Pharmacological Treatment for Persistent/Intractable Hiccups

When physical maneuvers fail or hiccups persist:

1. First-line medication:

   • Chlorpromazine: 25-50 mg orally three to four times daily 1
   • For severe cases requiring immediate control: 25-50 mg IM; if symptoms persist for 2-3 days, consider IV administration (25-50 mg in 500-1000 mL saline) 4

2. Alternative medications if chlorpromazine fails or is contraindicated:

   • For central causes: Baclofen 5
   • For peripheral causes: Metoclopramide 5
   • Other options: Gabapentin, serotonergic agonists, lidocaine 2

Treatment Algorithm Based on Cause

1. Identify if central or peripheral cause:

   • Central causes: Stroke, brain lesions, central nervous system injury
   • Peripheral causes: GERD, myocardial ischemia, phrenic nerve irritation, diaphragmatic irritation

2. Treatment based on cause:

   • Central causes: Baclofen as first choice
   • Peripheral causes: Metoclopramide as first choice
   • Unknown cause or emergency: Chlorpromazine 5

3. For terminal illness: Consider midazolam 5

Interventional Approaches for Refractory Cases

For hiccups that don't respond to medications:

1. Nerve blocks:

   • Phrenic nerve block
   • Vagal nerve block

2. Alternative therapies:

   • Acupuncture (particularly extracranial acupuncture) 6
   • Phrenic nerve stimulation 5

Special Considerations

• Elderly patients: Start with lower doses of chlorpromazine as they are more susceptible to hypotension and neuromuscular reactions 1, 4
• Pediatric patients: Chlorpromazine should generally not be used in children under 6 months of age except in potentially life-saving situations 1
• Monitoring: Watch for hypotension with parenteral administration of chlorpromazine; keep patient lying down for at least 30 minutes after injection 4

Common Pitfalls

• Failure to identify underlying cause: Many hiccups have treatable underlying causes that should be addressed (GERD, medications, electrolyte abnormalities)
• Inadequate dosing: Insufficient dosing of chlorpromazine may lead to treatment failure
• Overlooking drug interactions: Chlorpromazine can interact with many medications and cause sedation, hypotension
• Prolonged IV use: IV chlorpromazine should be diluted and administered slowly to avoid hypotension 4

Remember that while most hiccup episodes are benign and self-limited, persistent hiccups can significantly impact quality of life and may indicate serious underlying pathology that requires thorough investigation.