What are the treatment options for hiccups (synchronous diaphragmatic contractions)?

Treatment Options for Hiccups

For hiccups (synchronous diaphragmatic contractions), first attempt physical maneuvers such as breath-holding, rapid water drinking, or swallowing granulated sugar, followed by chlorpromazine 25-50 mg three times daily for persistent cases. 1

Classification of Hiccups

Hiccups can be categorized based on duration:

• 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, try these non-pharmacological approaches first:

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

These physical interventions work by interrupting the hiccup reflex arc and are recommended as initial management for most cases of acute hiccups 1.

Pharmacological Treatment

For Persistent Hiccups (>48 hours)

1. First-line medication: Chlorpromazine

   • Dosage: 25 mg three times daily orally
   • Adjustment: If ineffective after 2-3 days, increase to 50 mg three times daily
   • Administration: For intractable cases, consider IV administration under careful monitoring 1, 2

2. Alternative medications if chlorpromazine is contraindicated or ineffective:

   • Baclofen
   • Gabapentin
   • Metoclopramide (particularly effective for peripheral causes) 1, 3

Special Considerations for Intractable Hiccups

For hiccups persisting beyond 2 months:

• If oral therapy fails after 2-3 days, consider IM chlorpromazine 25-50 mg
• For continued symptoms, slow IV infusion may be used: 25-50 mg in 500-1000 mL of saline with close blood pressure monitoring 4

Treatment Algorithm Based on Hiccup Duration

1. Acute Hiccups (<48 hours)

   • Start with physical maneuvers
   • If bothersome and persistent, consider chlorpromazine 25 mg orally

2. Persistent Hiccups (48 hours - 2 months)

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

3. Intractable Hiccups (>2 months)

   • Consider parenteral chlorpromazine (IM or IV)
   • Evaluate for advanced interventions such as nerve blocks or nerve stimulation
   • Consider referral to specialists 1, 4

Addressing Underlying Causes

Hiccups often have underlying causes that should be identified and treated:

• Gastroesophageal reflux disease (GERD) - most common cause 5
• Central nervous system disorders
• Myocardial ischemia
• Metabolic disorders
• Medication side effects

For GERD-related hiccups, proton pump inhibitors should be considered as first-line therapy 5.

Safety Considerations

When using chlorpromazine:

• Monitor for hypotension, especially after parenteral administration
• Keep patient lying down for at least 30 minutes after injection
• Use lower doses in elderly, debilitated, or emaciated patients
• Watch for sedation and extrapyramidal symptoms
• Consider QT prolongation risk, especially when combining with other QT-prolonging medications 2, 4

Novel Approaches

For refractory cases, consider:

• Lidocaine: Oral application of 2% lidocaine solution or gel has shown success in case reports of intractable hiccups 6
• Nerve blocks: Phrenic or vagal nerve blocks for intractable cases
• Acupuncture: May be effective in some patients 3

Common Pitfalls

• Failing to identify and treat underlying causes can lead to prolonged hiccups
• Overlooking drug interactions with chlorpromazine
• Using high doses of chlorpromazine in elderly patients without appropriate monitoring
• Relying solely on physical maneuvers for persistent hiccups
• Not escalating therapy appropriately when initial treatments fail

By following this structured approach to hiccup management, most cases can be effectively treated while minimizing adverse effects and improving patient quality of life.