What is the best treatment for hiccups?

Best Treatment for Hiccups

For most hiccup cases, physical maneuvers should be attempted first, but chlorpromazine remains the only FDA-approved medication for persistent or intractable hiccups at a dose of 25-50 mg three to four times daily. 1, 2

First-Line Treatments: Physical Maneuvers

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

• 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) 3, 1

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

Medication Treatment for Persistent Hiccups

If hiccups persist beyond 48 hours (persistent hiccups) or beyond 2 months (intractable hiccups), pharmacological intervention is indicated:

1. Chlorpromazine (First-line):

   • Dosage: 25-50 mg orally three to four times daily 2
   • For severe cases: If symptoms persist for 2-3 days after oral therapy, switch to 25-50 mg IM 4
   • For truly intractable cases: Slow IV infusion of 25-50 mg in 500-1000 mL saline (patient should be lying flat with close blood pressure monitoring) 4

2. Alternative medications (when chlorpromazine is contraindicated or ineffective):

   • Baclofen
   • Gabapentin
   • Metoclopramide
   • Haloperidol
   • Amitriptyline 5, 6

Treatment Algorithm

1. For acute hiccups (<48 hours):

   • Start with physical maneuvers
   • If unsuccessful and hiccups are bothersome, consider chlorpromazine

2. For persistent hiccups (>48 hours but <2 months):

   • Begin chlorpromazine 25 mg three times daily
   • If ineffective after 2-3 days, increase to 50 mg three times daily
   • If still ineffective, consider IM administration

3. For intractable hiccups (>2 months):

   • Consider IV chlorpromazine under careful monitoring
   • If ineffective or contraindicated, try alternative agents like baclofen or gabapentin

Important Considerations

• Monitor for side effects: Chlorpromazine can cause hypotension, sedation, and extrapyramidal symptoms. Start with lower doses in elderly patients 2, 4
• Identify underlying causes: Persistent hiccups may indicate serious underlying conditions such as myocardial infarction, brain tumors, renal failure, gastroesophageal reflux disease, or other pathologies 6, 7
• Dosage adjustments: Use lower doses in elderly, debilitated, or emaciated patients 2
• Position during IV administration: Patient should be lying flat with close blood pressure monitoring 4

Common Pitfalls to Avoid

1. Failing to investigate persistent hiccups for underlying serious conditions
2. Administering IV chlorpromazine too rapidly (should be given as slow infusion)
3. Not monitoring blood pressure during parenteral administration
4. Using maximum doses in elderly or debilitated patients
5. Continuing ineffective treatments without trying alternatives

While chlorpromazine is the only FDA-approved medication for hiccups, the evidence for all pharmacological interventions remains limited, with most recommendations based on case reports and small studies rather than large randomized controlled trials 5, 8.