What are the treatment options for hiccups?

Treatment Options for Hiccups

For hiccups treatment, begin with simple physical maneuvers that stimulate the pharynx or disrupt respiratory rhythm, followed by pharmacological therapy with chlorpromazine (25-50 mg three to four times daily) if hiccups persist for more than 2-3 days.

First-Line Treatment: Physical Maneuvers

For brief episodes of hiccups, try these non-pharmacological approaches first:

• 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 (Larson's maneuver) 1

These physical maneuvers work by either stimulating the pharynx or disrupting the respiratory rhythm, which can terminate the hiccup reflex arc.

Pharmacological Treatment

If hiccups persist for 2-3 days despite physical maneuvers, medication therapy is indicated:

First-Line Medication:

• Chlorpromazine: 25-50 mg three to four times daily orally 2
• For severe cases requiring parenteral administration: 25-50 mg IM, or slow IV infusion with 25-50 mg in 500-1000 mL of saline (patient should be lying flat with close blood pressure monitoring) 3

Alternative Medications (if chlorpromazine is ineffective or contraindicated):

• Metoclopramide (for peripherally-caused hiccups) 4
• Baclofen (particularly effective for centrally-caused hiccups) 4, 5
• Gabapentin 6

Treatment Algorithm Based on Duration

1. Acute hiccups (less than 48 hours):

   • Begin with physical maneuvers
   • If unsuccessful, consider chlorpromazine

2. Persistent hiccups (48 hours to 2 months):

   • Identify and treat underlying cause if possible
   • Chlorpromazine 25-50 mg TID or QID
   • Consider alternative medications if no response

3. Intractable hiccups (more than 2 months):

   • Comprehensive evaluation for underlying pathology
   • Trial of multiple pharmacological agents
   • Consider nerve blockade, pacing, or acupuncture 6, 7

Considerations for Special Populations

• Elderly patients: Use lower doses of medications and monitor closely for side effects, particularly hypotension with chlorpromazine 2, 3
• Terminally ill patients: Midazolam may be useful when other treatments fail 5

Common Pitfalls to Avoid

1. Failing to identify and treat underlying causes (gastroesophageal reflux, gastritis, CNS disorders)
2. Inadequate dosing or premature discontinuation of effective medications
3. Not considering alternative approaches when first-line treatments fail
4. Overlooking the significant impact of persistent hiccups on quality of life, sleep, and nutrition

Underlying Causes to Consider

Persistent or intractable hiccups may be caused by:

• Central nervous system disorders (stroke, tumors)
• Gastrointestinal conditions (GERD, gastritis)
• Thoracic disorders (myocardial infarction)
• Metabolic disorders
• Medication side effects
• Post-surgical complications

Identifying and treating the underlying cause is essential for effective management of persistent hiccups 6, 4.