What are the treatment options for managing persistent hiccups?

Management of Persistent Hiccups

Chlorpromazine (25-50 mg three to four times daily) is the first-line pharmacological treatment for persistent hiccups, as it is the only FDA-approved medication for this condition. 1, 2

Classification of Hiccups

• Acute hiccups: Less than 48 hours
• Persistent hiccups: More than 48 hours but less than 2 months
• Intractable hiccups: More than 2 months

Treatment Algorithm

First-Line: Non-Pharmacological Interventions

For brief episodes of hiccups, try these physical maneuvers that work by disrupting the hiccup reflex arc:

1. Breath holding
2. Drinking water rapidly
3. Swallowing granulated sugar
4. Pulling on the tongue
5. Stimulating the uvula/pharynx
6. Larson's maneuver: applying pressure between the posterior border of the mandible and mastoid process 3, 1

Second-Line: Pharmacological Interventions

For Persistent Hiccups (>48 hours):

1. Chlorpromazine:
   • Initial dose: 25 mg three times daily
   • If ineffective after 2-3 days, increase to 50 mg three times daily 1, 2
   • Monitor for side effects: hypotension, sedation, extrapyramidal symptoms
   • Use lower doses in elderly, debilitated, or emaciated patients 1, 2

For Intractable Hiccups (>2 months):

If chlorpromazine is ineffective or contraindicated, consider:

1. Baclofen: Effective for central causes of hiccups 4, 5
2. Gabapentin: Particularly useful for neuropathic-related hiccups 4, 5
3. Metoclopramide: First choice for peripheral causes (especially GI-related) 4, 5

For Terminal Illness with Hiccups:

• Midazolam may be useful in palliative care settings 4

Mechanism-Based Approach

Hiccups result from a reflex arc involving phrenic, vagal, and sympathetic pathways with central midbrain modulation 6. Treatment can be targeted based on the likely cause:

Central Causes

• Stroke, space-occupying lesions, CNS injury
• Treatment of choice: Baclofen 4

Peripheral Causes

• Gastroesophageal reflux, myocardial ischemia, phrenic nerve irritation
• Treatment of choice: Metoclopramide 4

Special Considerations

Monitoring During Treatment

• For IV chlorpromazine: position patient lying flat and monitor blood pressure closely 1
• For all antipsychotics: monitor for extrapyramidal symptoms and sedation 1

Refractory Cases

For hiccups that don't respond to medication:

• Consider nerve blockade (phrenic or vagal)
• Acupuncture
• Nerve stimulation techniques 4

Underlying Causes to Investigate

Always evaluate for underlying causes that may require specific treatment:

• Gastroesophageal reflux disease
• Myocardial infarction
• Brain tumors
• Renal failure
• Medication side effects (steroids, anti-Parkinson drugs, anesthetics) 1, 6

The evidence for most hiccup treatments is limited, with recommendations largely based on case reports and small studies rather than large randomized controlled trials 1, 5. However, chlorpromazine remains the most established treatment with FDA approval specifically for hiccups 2.