What is the recommended medication treatment for hiccups?

Medication Treatment for Hiccups

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

Classification of Hiccups

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, 3

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 1

Step 2: Pharmacological Treatment (for persistent or intractable hiccups)

First-Line Medication:

• Chlorpromazine: 25-50 mg three times daily 1, 2
  • Initial dose: 25 mg three times daily
  • If ineffective after 2-3 days: increase to 50 mg three times daily
  • For intractable cases: IV administration may be considered under careful monitoring
  • Caution: Monitor for hypotension, sedation, and extrapyramidal symptoms
  • Dose reduction needed in elderly, debilitated, or emaciated patients

Alternative Medications (if chlorpromazine is ineffective or contraindicated):

1. Baclofen: Particularly effective for central causes of hiccups 1, 4
2. Gabapentin: Useful for neuropathic-related hiccups 1, 5
3. Metoclopramide: Effective for peripheral causes, especially GI-related hiccups 1, 6
4. Other options with less evidence:
   • Haloperidol
   • Amitriptyline
   • Nifedipine
   • Valproic acid 4

Special Considerations

Underlying Causes

Always evaluate for and treat underlying causes of persistent hiccups:

• Gastroesophageal reflux disease
• Myocardial ischemia
• Central nervous system disorders
• Medication side effects (steroids, anti-Parkinson drugs, anesthetics)
• Renal failure 1, 3, 6

Monitoring and Precautions

• Monitor for QT prolongation when using chlorpromazine, especially if combined with other QT-prolonging medications 1
• Lower doses of chlorpromazine are recommended for elderly patients due to increased risk of adverse effects 1, 2
• For patients with dystonic reactions to metoclopramide or prochlorperazine, diphenhydramine can be used 7

Refractory Cases

For hiccups that don't respond to medication, consider:

• Nerve blockade (phrenic or vagal)
• Acupuncture
• Nerve stimulation techniques 1, 3

Common Pitfalls to Avoid

1. Failing to identify and treat underlying causes, leading to prolonged or intractable hiccups
2. Overlooking drug interactions, particularly with QT-prolonging medications
3. Using high doses of chlorpromazine in elderly or debilitated patients without appropriate monitoring
4. Not adjusting therapy based on the suspected cause (central vs. peripheral)
5. Continuing ineffective treatments without trying alternative approaches 1

The stepwise approach from physical maneuvers to pharmacological therapy with chlorpromazine as the first-line medication provides the most evidence-based strategy for managing hiccups, with alternative medications available for cases that don't respond to initial treatment.