What are the treatment options for hiccups?

Treatment Options for Hiccups

For hiccups treatment, begin with physical maneuvers to stimulate the pharynx or disrupt respiratory rhythm, followed by pharmacological options such as chlorpromazine for persistent cases. 1

Classification and Treatment Approach

Acute Hiccups (less than 48 hours)

• First-line: Non-pharmacological interventions
  • Breath holding
  • Drinking water rapidly
  • Swallowing granulated sugar
  • Pulling on the tongue
  • Stimulating the uvula/pharynx
  • Larson's maneuver (applying pressure between the posterior border of the mandible and mastoid process) 1
• Address underlying causes
  • Gastric distention
  • Alcohol intake

Persistent Hiccups (48 hours to 2 months)

• Identify and treat underlying cause
• Pharmacological therapy:
  • For central causes: Baclofen
  • For peripheral causes: Metoclopramide
  • First-line medication: Chlorpromazine 25-50 mg three to four times daily orally 1, 2

Intractable Hiccups (beyond 2 months)

• Comprehensive diagnostic workup
• Pharmacotherapy options:
  • Chlorpromazine (25-50 mg t.i.d. or q.i.d.) 2, 3
  • Baclofen
  • Gabapentin
• Interventional procedures for refractory cases:
  • Nerve blocks
  • Acupuncture 4

Detailed Pharmacological Management

Chlorpromazine Administration

• Oral administration: 25-50 mg three to four times daily 2
• Intramuscular administration (if symptoms persist 2-3 days after oral therapy): 25-50 mg IM 3
• Intravenous administration (for severe cases): 25-50 mg in 500-1000 mL saline as slow IV infusion with close blood pressure monitoring 3

Special Populations

• Elderly patients: Use lower doses and monitor closely for hypotension and neuromuscular reactions 2, 3
• Palliative care patients: Consider midazolam for terminal cases of intractable hiccups 5

Important Clinical Considerations

• Persistent hiccups can significantly impact quality of life, causing depression, weight loss, and sleep deprivation 6
• Always investigate and address underlying conditions such as gastroesophageal reflux disease, gastritis, or ulcers 6
• When administering chlorpromazine:
  • Monitor for hypotension, especially with parenteral administration
  • Keep patient lying down for at least 30 minutes after injection
  • For IV administration, dilute properly and administer slowly 3

Treatment Algorithm Based on Hiccup Duration and Cause

1. For brief episodes:

   • Begin with non-pharmacological physical maneuvers
   • If unsuccessful after several attempts, consider short-term medication

2. For persistent episodes:

   • Conduct diagnostic evaluation to identify underlying cause
   • Select medication based on suspected etiology (central vs. peripheral)
   • For central causes: Baclofen
   • For peripheral causes: Metoclopramide
   • For unknown or mixed causes: Chlorpromazine

3. For intractable cases:

   • Consider combination pharmacotherapy
   • Evaluate for interventional procedures if medication fails
   • Consider acupuncture as an alternative approach 4

While numerous treatments have been reported over the years, no single "cure" stands out as universally effective 7. The approach must be systematic, starting with simple physical maneuvers and progressing to pharmacotherapy when necessary.