What are the treatment options for hiccups?

Treatment Options for Hiccups

Chlorpromazine (25-50 mg three to four times daily) is the most effective first-line medication for intractable hiccups, with FDA approval specifically for this indication. 1

Understanding Hiccups

Hiccups result from a reflex arc involving:

• Peripheral pathways (phrenic, vagal, and sympathetic) 2
• Central midbrain modulation 2
• Sudden diaphragmatic and intercostal muscle contraction followed by laryngeal closure 2

Hiccups are classified based on duration:

• Self-limited: Most common, resolving spontaneously
• Persistent: Lasting longer than 48 hours 2
• Intractable: Continuing for more than 2 months 2

First-Line Treatment Approaches

Non-Pharmacological Methods

Try these simple physical maneuvers first for benign, self-limited hiccups:

• Stimulation of the uvula or pharynx 3
• Disruption of diaphragmatic rhythm 3
• Breath-holding techniques 4
• Measures that interrupt normal respiratory patterns 3

Pharmacological Treatments

For persistent or intractable hiccups, medication therapy is indicated:

1. Chlorpromazine (First-line)

   • Dosage: 25-50 mg three to four times daily 1
   • FDA-approved specifically for intractable hiccups 1
   • Most widely employed agent for persistent hiccups 3

2. Based on cause (central vs. peripheral)

   • For central causes: Baclofen is drug of choice 4
   • For peripheral causes: Metoclopramide is recommended as first choice 4

Advanced Treatment Options

For hiccups refractory to first-line treatments:

• Other medications:

  • Gabapentin 2
  • Baclofen 2
  • Serotonergic agonists 2
  • Lidocaine (oral application) 5
  • Midazolam (particularly in terminal illness) 4

• Interventional procedures:

  • Nerve blockade (phrenic or vagal) 4
  • Nerve stimulation 4
  • Acupuncture 2

Treatment Algorithm

1. Identify and treat underlying cause if possible 2
2. Try non-pharmacological measures (breath holding, physical maneuvers) 3
3. First-line medication: Chlorpromazine 25-50 mg TID or QID 1
4. If ineffective, determine if central or peripheral cause:
   • Central: Try baclofen 4
   • Peripheral: Try metoclopramide 4
5. For refractory cases: Consider gabapentin, lidocaine, or interventional procedures 2, 5
6. For terminal illness: Consider midazolam 4

Important Considerations

• Chlorpromazine may cause hypotension and neuromuscular reactions, particularly in elderly patients who should be monitored closely 1
• For elderly patients, start with lower doses and increase gradually 1
• Persistent hiccups can significantly impact quality of life and should be treated aggressively 4
• The effectiveness of many hiccup remedies is based on anecdotal evidence rather than controlled clinical studies 3