What is the treatment for hiccups (singultus)?

Treatment of Hiccups (Singultus)

Chlorpromazine is the most effective first-line pharmacological treatment for persistent or intractable hiccups, with a recommended dosage of 25-50 mg three to four times daily. 1

Classification of Hiccups

Hiccups can be categorized based on duration:

• Acute: Less than 48 hours (most common)
• Persistent: Lasting 48 hours to 2 months
• Intractable: Lasting more than 2 months 2

First-Line Non-Pharmacological Approaches

For acute, self-limited hiccups, try these physical maneuvers first:

• Breathing techniques:

  • Hold breath technique: Complete inspiration followed by breath-holding 3
  • Paper bag rebreathing: Creates transient hypercapnia 3
  • HAPI technique (Hiccup relief using Active Prolonged Inspiration): Maximal inspiration followed by continued inspiratory effort with open glottis for 30 seconds 4

• Physical maneuvers:

  • Stimulation of the nasopharynx (drinking water rapidly) 2
  • Interruption of normal respiratory rhythm 2
  • Vagal stimulation techniques (carotid massage, Valsalva maneuver) 2

Pharmacological Treatment

When non-pharmacological approaches fail or for persistent/intractable hiccups:

1. First-line medication:

   • Chlorpromazine 25-50 mg orally three to four times daily 1
   • FDA-approved specifically for intractable hiccups 1

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

   • Baclofen 2
   • Gabapentin 2
   • Metoclopramide (especially if GI-related cause) 2
   • Lidocaine 2

Management Algorithm

1. For acute hiccups (<48 hours):

   • Start with non-pharmacological approaches 2, 3
   • If persistent beyond several hours and causing distress, consider chlorpromazine 1

2. For persistent hiccups (>48 hours):

   • Evaluate for underlying causes (GI, neurological, metabolic, etc.) 2, 5
   • Initiate chlorpromazine 25-50 mg TID or QID 1
   • Consider alternative medications if ineffective 2

3. For intractable hiccups (>2 months):

   • Comprehensive evaluation for serious underlying pathology 2, 5
   • Multidisciplinary approach may be needed 5
   • Consider nerve blocks or surgical interventions in refractory cases 2

Special Considerations

• Underlying causes: Always investigate and treat underlying causes, especially for persistent or intractable hiccups 2, 5
• Common etiologies: Gastric distension, GERD, CNS disorders, metabolic disturbances, medication side effects 5
• Caution: Monitor for extrapyramidal side effects with chlorpromazine, especially in elderly patients 1

Pitfalls to Avoid

• Failing to recognize persistent hiccups as a potential sign of serious underlying pathology 5
• Overlooking drug-induced hiccups (steroids, benzodiazepines, chemotherapy agents) 2
• Excessive focus on symptomatic treatment without addressing underlying causes 5
• Delaying pharmacological intervention in cases causing significant distress or sleep disruption 2