Management of Persistent Hiccups
Chlorpromazine is the first-line pharmacological treatment for persistent hiccups, with an initial dose of 25 mg three times daily, which can be increased to 50 mg three times daily if ineffective after 2-3 days. 1
Classification of Hiccups
Hiccups can be categorized 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
Treatment Algorithm
Step 1: Physical Maneuvers (First-Line 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 (supraglottic swallow)
Step 2: Pharmacological Treatment for Persistent Hiccups
First-Line Medication:
- Chlorpromazine:
- Initial dose: 25-50 mg three times daily 1, 2
- If symptoms persist for 2-3 days, increase to 50 mg three times daily 1
- For intractable cases not responding to oral therapy, consider IM administration: 25-50 mg 3
- For severe cases unresponsive to IM, consider slow IV infusion: 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: Recommended for central causes of hiccups 1, 4
- Gabapentin: Effective for neuropathic-related hiccups 1, 5
- Metoclopramide: Particularly effective for peripheral/GI-related hiccups 1, 4
- Other options with some evidence: amitriptyline, haloperidol, midazolam, nifedipine, nimodipine, orphenadrine, and valproic acid 5
Step 3: Interventional Approaches for Refractory Cases
For hiccups that don't respond to medication:
- Nerve blockade (phrenic or vagal)
- Acupuncture
- Nerve stimulation techniques
- Osteopathic manipulative treatment 6
Special Considerations
Underlying Causes
Always evaluate for and treat underlying causes, which may include:
- Gastroesophageal reflux disease
- Myocardial ischemia/infarction
- Central nervous system disorders (stroke, tumors)
- Renal failure
- Medication side effects (steroids, anti-Parkinson drugs, anesthetics)
Dosage Adjustments
- For elderly, debilitated, or emaciated patients: Use lower doses and increase more gradually 2, 3
- Monitor for side effects such as hypotension, sedation, and extrapyramidal symptoms 1
- Watch for QT prolongation, especially if combined with other QT-prolonging medications 1
Evidence Quality
The evidence for hiccup treatments is generally of low to moderate quality. Chlorpromazine is the only FDA-approved medication for hiccups 5, but there are limited high-quality randomized controlled trials comparing different treatments. A Cochrane review found insufficient evidence to guide treatment with either pharmacological or non-pharmacological interventions 7.
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 or debilitated patients without appropriate monitoring
- Not escalating to alternative treatments when first-line therapy fails
By following this systematic approach, most cases of persistent hiccups can be effectively managed, improving patient quality of life and reducing morbidity associated with this distressing condition.