Causes and Treatment of Persistent Hiccups
Chlorpromazine is the first-line pharmacological treatment for persistent hiccups that don't respond to physical maneuvers, with an initial dose of 25-50 mg three times daily, which can be increased if ineffective after 2-3 days. 1
Classification of Hiccups
Hiccups are classified based on duration:
- Acute hiccups: Less than 48 hours
- Persistent hiccups: More than 48 hours but less than 2 months
- Intractable hiccups: More than 2 months
Causes of Persistent Hiccups
Hiccups result from irritation of the hiccup reflex arc, which involves peripheral phrenic, vagal, and sympathetic pathways with central midbrain modulation 2. Causes can be divided into:
Central Causes
- Stroke
- Brain tumors or space-occupying lesions
- Central nervous system injury
- Neurodegenerative disorders
Peripheral Causes
- Gastrointestinal: GERD, gastritis, pancreatitis, distention
- Thoracic: Myocardial ischemia, pericarditis, pneumonia
- Irritation of the diaphragm: Subdiaphragmatic abscess
- Procedural: Nasogastric tube insertion, post-surgical
- Metabolic: Uremia, electrolyte imbalances
Medication-Induced
- Steroids
- Anti-Parkinson medications
- Anesthetic agents
- Chemotherapy drugs
Treatment Algorithm
Step 1: Physical Maneuvers (for acute hiccups)
Try these simple techniques first:
- Breath holding
- Drinking water rapidly
- Swallowing granulated sugar
- Pulling on the tongue
- Stimulating the uvula/pharynx
- Larson's maneuver (placing pressure between the mandible and mastoid process) 3
- Digital rectal massage (reported in case studies) 4
Step 2: Pharmacological Treatment (for persistent hiccups)
First-line treatment:
- Chlorpromazine: 25-50 mg orally three times daily 1, 5
- If ineffective after 2-3 days, increase dose up to 50 mg three times daily
- For elderly or debilitated patients, use lower doses
- For intractable hiccups not responding to oral therapy, consider IM injection (25-50 mg) 6
- For severe cases, slow IV infusion may be used (25-50 mg in 500-1000 mL saline) with close blood pressure monitoring 6
Alternative medications (if chlorpromazine is ineffective or contraindicated):
- For central causes: Baclofen 1, 7
- For peripheral/GI-related causes: Metoclopramide 1, 7
- For neuropathic-related hiccups: Gabapentin 1
- For terminal illness: Midazolam 7
Step 3: Interventional Procedures (for refractory cases)
Consider these options when medications fail:
- Nerve blockade (phrenic or vagal)
- Nerve stimulation techniques
- Acupuncture
Special Considerations
Monitoring and Side Effects
- When using chlorpromazine, monitor for:
- Hypotension (especially with IV administration)
- Sedation
- Extrapyramidal symptoms
- Keep patient lying down for at least 30 minutes after injection 6
Elderly Patients
- Use lower doses of medications
- Monitor more closely for side effects
- Increase dosage more gradually 5, 6
Treating Underlying Causes
Always identify and treat any underlying condition causing the hiccups:
- Treat GERD with acid suppressants
- Address electrolyte imbalances
- Adjust medications that may be triggering hiccups
- Manage any central nervous system disorders
Pitfalls to Avoid
- Don't continue ineffective physical maneuvers for prolonged periods when pharmacological intervention is needed
- Avoid delaying treatment of persistent hiccups, as they can lead to exhaustion, dehydration, weight loss, and significant reduction in quality of life
- Don't overlook serious underlying causes that may require specific treatment
- Be cautious with chlorpromazine in patients with cardiovascular disease or seizure disorders
- Never inject undiluted chlorpromazine directly into a vein 6
By following this systematic approach to diagnosis and treatment, most cases of persistent hiccups can be effectively managed, improving patient comfort and quality of life.