How to manage hiccups?

Management of Hiccups

For hiccups, begin with physical maneuvers like breath holding or drinking water rapidly, then progress to pharmacological therapy with chlorpromazine 25-50 mg three times daily for persistent cases. 1

Classification and Approach

Hiccups are classified into three categories based on duration:

• Acute: less than 48 hours
• Persistent: more than 48 hours but less than 2 months
• Intractable: more than 2 months 1

Step-by-Step Management Algorithm

1. First-Line: Physical Maneuvers

For acute hiccups, try these simple techniques to disrupt the hiccup reflex arc:

• Breath holding
• Drinking water rapidly
• Swallowing granulated sugar
• Pulling on the tongue
• Stimulating the uvula/pharynx
• Larson's maneuver (suprasternal pressure) 1

2. Second-Line: Pharmacological Therapy

If physical maneuvers fail or hiccups persist beyond 48 hours:

• For persistent hiccups:

  • Chlorpromazine 25 mg three times daily
  • If ineffective after 2-3 days, increase to 50 mg three times daily 1, 2

• For intractable hiccups:

  • Continue chlorpromazine with careful monitoring
  • Consider alternative medications if chlorpromazine is ineffective:
    • Baclofen for central causes
    • Gabapentin for neuropathic-related hiccups
    • Metoclopramide for GI-related hiccups 1, 3

Special Considerations

Dosage Adjustments

• Use lower doses in elderly, debilitated, or emaciated patients
• For elderly patients: Start at lower range and monitor closely for hypotension and neuromuscular reactions 1, 2

Underlying Causes

Always evaluate for potential underlying causes:

• Gastroesophageal reflux disease (most common) 4
• Myocardial ischemia
• Central nervous system disorders
• Renal failure
• Medication side effects (steroids, anti-Parkinson drugs, anesthetics) 1

Refractory Cases

For hiccups that don't respond to standard therapy:

• Consider nerve blockade (phrenic or vagal)
• Acupuncture
• Nerve stimulation techniques 1

Monitoring and Precautions

• Monitor for QT prolongation, especially if combined with other QT-prolonging medications
• Watch for side effects of chlorpromazine:
  • Hypotension
  • Sedation
  • Extrapyramidal symptoms 1, 2

Common Pitfalls to Avoid

• Failing to identify and treat underlying causes can lead to prolonged or intractable hiccups
• Overlooking drug interactions, particularly with QT-prolonging medications
• Using high doses of chlorpromazine in elderly patients without appropriate monitoring 1

Evidence Quality

The recommendations for physical maneuvers and chlorpromazine as first-line pharmacological treatment are based on moderate-quality evidence from clinical guidelines 1. While many treatments have been reported over the years, chlorpromazine remains one of the most widely employed agents for persistent hiccups 5, with FDA approval specifically for intractable hiccups 2.