What is the treatment approach for hiccups (singultus) in patients?

Treatment Approach for Hiccups (Singultus) in Patients

For intractable hiccups, chlorpromazine 25-50 mg three to four times daily is the first-line pharmacological treatment, with escalation to intravenous therapy if oral treatment fails after 2-3 days. 1

Understanding Hiccups

Hiccups (singultus) are characterized by sudden, erratic contractions of the diaphragmatic and intercostal muscles followed immediately by laryngeal closure, producing the characteristic "hic" sound. 2

• Hiccups are classified based on duration:
  • Acute: Self-limited episodes lasting less than 48 hours 2
  • Persistent: Episodes lasting more than 48 hours 2
  • Intractable: Episodes lasting more than 2 months 2

Treatment Algorithm

Step 1: Non-pharmacological Approaches (First-line for acute hiccups)

• Physical maneuvers to interrupt the hiccup reflex:
  • Breath holding techniques 3
  • Suboccipital release: Applying gentle traction and pressure to the posterior neck to stretch suboccipital muscles and fascia 4
  • Larson's maneuver: Placing middle fingers in the "laryngospasm notch" between posterior border of mandible and mastoid process while displacing mandible forward in a jaw thrust 5
  • Continuous positive airway pressure with 100% oxygen using a reservoir bag and facemask 5

Step 2: Pharmacological Treatment for Persistent/Intractable Hiccups

For Central Causes:

• First-line: Baclofen 3
• Alternative options:
  • Gabapentin 2
  • Midazolam (particularly in terminal illness) 3

For Peripheral Causes:

• First-line: Metoclopramide 3
• Alternative options:
  • Prokinetics 2
  • Serotonergic agonists 2

For Intractable Hiccups:

• First-line: Chlorpromazine
  • Oral dosage: 25-50 mg three to four times daily 1
  • If symptoms persist for 2-3 days, switch to parenteral therapy:
    • IM: 25-50 mg 6
    • IV (for severe cases): 25-50 mg in 500-1000 mL saline as slow infusion with close blood pressure monitoring 6
  • FDA-approved specifically for intractable hiccups 6

Step 3: Interventional Procedures (For refractory cases)

• Nerve blockade (vagal or phrenic nerve) 3
• Nerve stimulation 3
• Acupuncture 2

Special Considerations

• Elderly patients: Use lower doses of medications, particularly chlorpromazine, as they are more susceptible to hypotension and neuromuscular reactions 1, 6
• Monitoring: When using IV chlorpromazine, monitor blood pressure closely as rapid infusion may cause hypotension 6
• Underlying causes: Always investigate and treat any underlying causes of persistent hiccups, which may include:
  • Gastroesophageal reflux disease 2, 7
  • Neurological disorders 2, 7
  • Space-occupying lesions 2
  • Myocardial ischemia 2
  • Medication side effects 2

Cautions and Pitfalls

• Chlorpromazine can cause hypotension, particularly with IV administration - keep patient lying down for at least 30 minutes after injection 6
• Avoid subcutaneous injection of chlorpromazine 6
• For IV administration of chlorpromazine, always dilute to at least 1 mg/mL and administer at a rate of 1 mg per minute 6
• Consider that persistent or intractable hiccups may indicate serious underlying pathology requiring specific treatment 7