How to manage hiccups?

Management of Hiccups

For hiccups, use a stepwise approach starting with physical maneuvers for acute cases, progressing to chlorpromazine (25-50 mg three times daily) for persistent cases, and considering specialized interventions for intractable hiccups. 1

Classification of Hiccups

• Acute: Less than 48 hours
• Persistent: More than 48 hours but less than 2 months
• Intractable: More than 2 months

First-Line Treatment: Physical Maneuvers

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

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

These physical techniques work by disrupting the hiccup reflex arc and are recommended as first-line treatment by multiple medical societies 1.

Pharmacological Treatment

If physical maneuvers fail or hiccups persist beyond 48 hours:

First-Line Medication

• Chlorpromazine: 25-50 mg three times daily 1, 2
  • For persistent cases, start with 25 mg three times daily
  • Can increase to 50 mg three times daily if ineffective after 2-3 days
  • FDA-approved for intractable hiccups 2, 3

Alternative Medications (if chlorpromazine is contraindicated or ineffective)

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

Treatment Algorithm Based on Duration

For Acute Hiccups (<48 hours)

1. Start with physical maneuvers
2. If bothersome and persistent despite maneuvers, consider chlorpromazine

For Persistent Hiccups (>48 hours but <2 months)

1. Chlorpromazine 25 mg three times daily
2. If ineffective after 2-3 days, increase to 50 mg three times daily
3. Consider alternative medications if chlorpromazine fails

For Intractable Hiccups (>2 months)

1. IV chlorpromazine under careful monitoring
2. Consider specialized interventions:
   • Nerve blocks
   • Nerve stimulation
   • Acupuncture 1, 5

Special Considerations and Precautions

Medication Administration

• For oral chlorpromazine: 25-50 mg three times daily 2
• For intramuscular administration: 25-50 mg, can repeat if necessary 3
• For intravenous administration (severe cases): 25-50 mg diluted in 500-1000 mL saline, administered with patient lying flat 3

Monitoring

• Watch for hypotension, especially with parenteral administration
• Monitor for sedation and extrapyramidal symptoms
• Use lower doses in elderly, debilitated, or emaciated patients 1, 2
• Be aware of QT prolongation risk, especially when combining with other medications 1

Underlying Causes

Always investigate for potential underlying causes of persistent hiccups:

• Gastroesophageal reflux disease
• Central nervous system disorders
• Thoracic disorders
• Metabolic abnormalities
• Medication side effects 4, 6

Failure to identify and treat underlying causes can lead to prolonged or intractable hiccups. The hiccup reflex involves a complex pathway including phrenic, vagal, and sympathetic nerves with central midbrain modulation 4.

Pediatric Considerations

For children 6 months to 12 years:

• Physical maneuvers should be tried first
• If medication is needed, chlorpromazine dosing is weight-based: ¼ mg/lb body weight every 4-6 hours 2, 3
• Not recommended for children under 6 months except in potentially life-saving situations 2