What is the management for hiccups (singultus)?

Management of Hiccups (Singultus)

For hiccups, treatment should follow a stepwise approach starting with physical maneuvers for acute cases, progressing to chlorpromazine as first-line medication for persistent cases, with baclofen or gabapentin as alternatives depending on the underlying cause. 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 (<48 hours), try these non-pharmacological interventions:

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

These techniques can effectively disrupt the hiccup reflex arc and are recommended as initial treatment by multiple medical societies 1.

Pharmacological Treatment

For Persistent Hiccups (>48 hours)

1. Chlorpromazine (first-line medication):

   • Initial dose: 25 mg orally three times daily
   • Can increase to 50 mg three times daily if ineffective after 2-3 days
   • For severe cases: 25-50 mg IM, or slow IV infusion with patient lying flat 2, 3

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

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

Treatment Algorithm Based on Duration and Severity

Acute Hiccups (<48 hours)

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

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 based on suspected cause

Intractable Hiccups (>2 months)

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

Special Considerations

Monitoring and Precautions

• Monitor patients taking chlorpromazine for:
  • Hypotension (especially with IV administration)
  • Sedation
  • Extrapyramidal symptoms
• Reduce dosage for elderly, debilitated, or emaciated patients 1, 2
• Consider QT prolongation risk, especially when combining with other QT-prolonging medications

Identifying Underlying Causes

Always investigate and treat underlying causes of persistent hiccups, which may include:

• Gastroesophageal reflux disease
• Myocardial ischemia
• Central nervous system disorders
• Medication side effects
• Metabolic disorders 1, 5

Common Pitfalls to Avoid

• Failing to identify and treat underlying causes
• Overlooking drug interactions, particularly with QT-prolonging medications
• Using high doses of chlorpromazine in elderly or debilitated patients
• Not adjusting treatment based on whether the cause is central or peripheral
• Continuing ineffective treatments without trying alternatives 1

For patients with terminal illness where other treatments have failed, midazolam may be considered, particularly in palliative care settings 4.