What is the treatment for severe hiccups?

Treatment for Severe Hiccups

For severe hiccups, chlorpromazine is the first-line pharmacological treatment at a dose of 25-50 mg three times daily, which can be increased if ineffective after 2-3 days. 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

Treatment Algorithm

Step 1: Physical Maneuvers (First-line 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 (pulling knees to chest)

Step 2: Pharmacological Treatment

If physical maneuvers fail or for persistent/intractable hiccups:

First-line medication:

• Chlorpromazine:
  • Oral: 25-50 mg three times daily 1, 2
  • If symptoms persist for 2-3 days, switch to parenteral therapy:
    • IM: 25-50 mg (1-2 mL) 3
    • IV (for intractable cases): 25-50 mg in 500-1000 mL saline as slow infusion with patient lying flat 3

Alternative medications (if chlorpromazine is ineffective or contraindicated):

• Baclofen: For central causes of hiccups 1, 4
• Gabapentin: For neuropathic-related hiccups 1, 5
• Metoclopramide: For peripheral causes, especially GI-related hiccups 1, 4

Special Considerations

Monitoring and Side Effects

• Monitor for QT prolongation, especially if combined with other QT-prolonging medications 1
• Watch for hypotension, sedation, and extrapyramidal symptoms 1
• Use lower doses in elderly, debilitated, or emaciated patients 2, 3
• Keep patient lying down for at least 30 minutes after injection 3

Underlying Causes

Always identify and treat underlying causes of persistent hiccups, such as:

• Gastroesophageal reflux disease (GERD) - most common cause 6
• Myocardial ischemia
• Central nervous system disorders
• Medications
• Metabolic disorders

Refractory Cases

For hiccups that don't respond to standard treatments:

• Consider nerve blockade (phrenic or vagal) 4
• Nerve stimulation 4
• Acupuncture 5

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
• Injecting undiluted chlorpromazine directly into veins (IV route is only for severe hiccups, surgery, and tetanus) 3

Remember that while most hiccups are self-limiting, persistent or intractable hiccups can significantly impact quality of life and may indicate serious underlying pathology that requires thorough evaluation and targeted treatment.