What are the treatment options for hiccups?

Treatment Options for Hiccups

For hiccups management, begin with physical maneuvers for acute cases, then progress to chlorpromazine (25-50 mg three times daily) for persistent cases, as recommended by multiple medical societies. 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

Step-by-Step Treatment Algorithm

First-Line: Physical Maneuvers

For acute hiccups (<48 hours), try these techniques:

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

These physical techniques work by disrupting the hiccup reflex arc and are recommended as initial management by multiple medical societies 1.

Second-Line: Pharmacological Therapy

If physical maneuvers fail or hiccups persist beyond 48 hours:

1. Chlorpromazine (First-line medication):

   • Dosing: 25-50 mg orally three times daily 1, 2
   • Adjustment: Can increase to 50 mg three times daily if ineffective after 2-3 days
   • FDA-approved: Specifically indicated for intractable hiccups 2, 3
   • Monitoring: Watch for hypotension, sedation, and extrapyramidal symptoms

2. Alternative medications (if chlorpromazine is ineffective or contraindicated):

   • Baclofen: Preferred for central causes of hiccups
   • Gabapentin: Preferred for neuropathic-related hiccups
   • Metoclopramide: Preferred for GI-related hiccups 1, 4

Third-Line: Advanced Interventions

For intractable hiccups (>2 months):

• IV chlorpromazine: 25-50 mg diluted in 500-1000 mL saline, administered as slow infusion with patient lying flat 3
• Nerve blockade: Consider phrenic nerve block for refractory cases
• Referral to specialists: For consideration of interventional approaches 1

Special Considerations

Elderly Patients

• Use lower doses of chlorpromazine (start at lower end of dosing range)
• Monitor closely for hypotension and neuromuscular reactions
• Increase dosage more gradually 2, 3

Underlying Causes

Always investigate and treat underlying causes, which may include:

• Gastroesophageal reflux disease
• Gastritis or peptic ulcer disease
• Myocardial ischemia
• Central nervous system disorders
• Medication side effects 1, 4

Cautions

• QT prolongation: Monitor when using chlorpromazine, especially if combined with other QT-prolonging medications
• Elderly patients: Use lower doses due to increased risk of adverse effects
• Debilitated patients: Increase dosage more gradually 1, 2

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 or debilitated patients without careful monitoring
• Delaying treatment of persistent hiccups, which can lead to complications like weight loss, sleep deprivation, and depression 1, 5

The evidence supporting most hiccup treatments is relatively low quality, but chlorpromazine remains the only FDA-approved medication specifically for intractable hiccups 2, 3. For most acute cases, physical maneuvers are sufficient, while persistent cases warrant a more aggressive pharmacological approach.