What are the treatment options for hiccups (singultus)?

Treatment Options for Hiccups (Singultus)

For hiccups (singultus), treatment should follow a stepwise approach starting with physical maneuvers, followed by pharmacological therapy with chlorpromazine as the first-line medication for persistent cases. 1

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

First-Line Treatment: Physical Maneuvers

For acute hiccups (<48 hours), try these non-pharmacological interventions first:

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

These techniques can effectively disrupt the hiccup reflex arc by interrupting the vagal and phrenic nerve pathways 1.

Pharmacological Treatment

If physical maneuvers fail or for persistent hiccups:

First-line medication:

• Chlorpromazine:
  • Initial dose: 25 mg three times daily orally 1, 2
  • Can increase to 50 mg three times daily if ineffective after 2-3 days 1
  • For intractable hiccups: If symptoms persist for 2-3 days after oral therapy, give 25-50 mg IM 3
  • For severe cases: Consider slow IV infusion with 25-50 mg in 500-1000 mL saline (patient should be lying flat with close blood pressure monitoring) 3

Alternative medications (if chlorpromazine is ineffective or contraindicated):

• Baclofen: Particularly effective for central causes of hiccups 1
• Gabapentin: Useful for neuropathic-related hiccups 1
• Metoclopramide: Consider for GI-related hiccups 1

Treatment Based on Duration

Acute Hiccups (<48 hours)

1. Physical maneuvers
2. If bothersome and persistent: Chlorpromazine 25 mg orally three times daily

Persistent Hiccups (>48 hours but <2 months)

1. Chlorpromazine 25 mg three times daily
2. If ineffective after 2-3 days, increase to 50 mg three times daily
3. Consider alternative agents if chlorpromazine fails

Intractable Hiccups (>2 months)

1. IV chlorpromazine under careful monitoring
2. Consider nerve blockade, acupuncture, or nerve stimulation techniques if medications fail

Special Considerations

Monitoring During Treatment

• Watch for hypotension, sedation, and extrapyramidal symptoms with chlorpromazine
• Monitor for QT prolongation, especially if combined with other QT-prolonging medications
• Use lower doses in elderly, debilitated, or emaciated patients 2, 3

Addressing Underlying Causes

Always evaluate and treat potential underlying causes of persistent hiccups:

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

Novel Approaches

• Lidocaine: Oral application of lidocaine solution or gel has shown success in treating intractable hiccups in cancer patients 4
• Osteopathic manipulative treatment: May be effective by targeting the vagus and phrenic nerves 5
• Suboccipital release: A manual therapy technique that applies gentle traction to the posterior neck, potentially interrupting the hiccup reflex 6

Common Pitfalls to Avoid

• Failing to identify and treat underlying causes
• Overlooking drug interactions, particularly with QT-prolonging medications
• Using high doses of chlorpromazine in elderly patients without proper monitoring
• Delaying treatment of persistent hiccups, which can significantly impact quality of life

By following this stepwise approach and addressing any underlying causes, most cases of hiccups can be effectively managed, improving patient comfort and quality of life.