What are the treatment options for hiccups?

Treatment Options for Hiccups

For hiccups, begin with non-pharmacological interventions like breath holding or drinking water rapidly, and if persistent beyond 48 hours, chlorpromazine 25-50 mg three to four times daily is the only FDA-approved medication and should be used as first-line pharmacological treatment. 1, 2

Classification and Approach

Hiccups are categorized based on duration:

• Acute hiccups: <48 hours
• Persistent hiccups: >48 hours but <2 months
• Intractable hiccups: >2 months

First-Line: Non-Pharmacological Interventions

For brief episodes of hiccups, try these physical maneuvers that work by either stimulating the pharynx or disrupting normal respiratory rhythm 1:

• 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)

Second-Line: Pharmacological Interventions

If non-pharmacological measures fail:

1. Chlorpromazine (first-line medication):

   • Dosage: 25-50 mg three to four times daily 1, 2
   • Only FDA-approved medication for persistent/intractable hiccups
   • For persistent hiccups, start with 25 mg three times daily; if ineffective after 2-3 days, increase to 50 mg three times daily 1
   • For elderly, debilitated, or emaciated patients, use lower doses with careful monitoring 2

2. Alternative agents (if chlorpromazine is ineffective or contraindicated):

   • Baclofen
   • Gabapentin
   • Metoclopramide
   • Serotonergic agonists
   • Prokinetics
   • Lidocaine 1, 3

Special Considerations

Monitoring and Precautions

• Monitor patients on chlorpromazine for side effects including hypotension, sedation, and extrapyramidal symptoms 1
• Position patients lying flat with close blood pressure monitoring during IV administration 1

Underlying Causes

Always investigate for underlying causes of persistent hiccups 1, 4:

• Gastroesophageal disorders (GERD, gastritis, ulcers)
• Myocardial infarction
• Brain tumors
• Renal failure
• Infections
• Medication side effects

Treatment Algorithm

1. For acute hiccups (<48 hours):

   • Start with physical maneuvers
   • If unsuccessful and bothersome, consider chlorpromazine 1

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
   • Investigate for underlying causes 1, 4

3. For intractable hiccups (>2 months):

   • Consider IV chlorpromazine under careful monitoring
   • Try alternative agents if chlorpromazine fails
   • Consider specialty consultation for nerve blockade, pacing, or acupuncture in refractory cases 1, 3

While many hiccup remedies have been reported over centuries, chlorpromazine remains the most evidence-supported pharmacological treatment, though the overall evidence quality is considered low, with most recommendations based on case reports and small studies rather than large randomized controlled trials 1, 5.