Treatment of Hiccups
For intractable hiccups, chlorpromazine 25-50 mg orally three to four times daily is the most effective first-line pharmacological treatment. 1
Understanding Hiccups
Hiccups (singultus) are involuntary contractions of the diaphragm and intercostal muscles followed by sudden closure of the glottis, producing the characteristic "hic" sound. They can be classified based on duration:
- Acute: Less than 48 hours
- Persistent: 48 hours to 2 months
- Intractable: More than 2 months
Treatment Algorithm
Step 1: Non-pharmacological Interventions
For acute, self-limited hiccups, try these physical maneuvers first:
- Stimulation of the uvula or pharynx
- Disruption of diaphragmatic rhythm
- Breath holding techniques
- Drinking water from the opposite side of a glass
- Gargling with cold water
- Applying gentle pressure to the eyeballs
- Pulling the knees up to the chest
Step 2: Pharmacological Treatment
If hiccups persist beyond simple measures:
For peripheral causes (gastric distention, GERD, etc.):
- Metoclopramide as first-line treatment
For central causes (stroke, brain tumors, etc.):
- Baclofen as first-line treatment
For intractable hiccups regardless of cause:
- Chlorpromazine 25-50 mg orally three to four times daily 1
- If symptoms persist for 2-3 days despite oral therapy, switch to intramuscular chlorpromazine 25-50 mg 2
- For severe cases unresponsive to IM therapy, consider IV chlorpromazine via slow infusion (25-50 mg in 500-1000 mL saline) with close blood pressure monitoring 2
Step 3: Advanced Interventions
For refractory cases:
- Nerve blocks (phrenic or vagal)
- Acupuncture
- Surgical intervention (in extreme cases)
Special Considerations
Underlying Causes
Always investigate and treat potential underlying causes:
- Gastric distention
- Gastroesophageal reflux disease
- Myocardial infarction
- Central nervous system disorders
- Metabolic disorders
- Medication side effects
Cautions with Chlorpromazine
- Monitor for hypotension, especially in elderly patients
- Watch for extrapyramidal symptoms
- Sedation may occur
- QT prolongation with repeated doses
Alternative Pharmacological Options
If chlorpromazine is contraindicated or ineffective:
- Gabapentin
- Lidocaine
- Serotonergic agonists
- Prokinetic agents
Conclusion
While most hiccups are benign and self-limited, persistent or intractable hiccups can significantly impact quality of life. A stepwise approach starting with non-pharmacological measures and progressing to pharmacological interventions with chlorpromazine as the mainstay of treatment offers the best chance for resolution.