What is the treatment for prolonged hiccups?

Treatment of Prolonged Hiccups

For prolonged hiccups, chlorpromazine (25-50 mg three to four times daily) is the first-line pharmacological treatment, with baclofen, gabapentin, and metoclopramide as effective alternatives if initial therapy fails. 1

Definition and Classification

• Hiccups (singultus) are sudden contractions of the diaphragmatic and intercostal muscles followed by laryngeal closure, producing the characteristic "hic" sound 2
• Classification based on duration:
  • Acute: self-limited episodes (less than 48 hours)
  • Persistent: episodes lasting more than 48 hours
  • Intractable: episodes lasting more than 2 months 2

Treatment Algorithm

First-Line Non-Pharmacological Interventions

1. Physical maneuvers that stimulate the vagus nerve:

   • Larson's maneuver: apply deep pressure at the "laryngospasm notch" between the posterior border of the mandible and mastoid process while performing a jaw thrust 3
   • Valsalva maneuver or breath holding techniques 4
   • HAPI technique (Hiccup relief using Active Prolonged Inspiration): maximal inspiration followed by continued inspiratory effort with open glottis for 30 seconds, then slow expiration 5
   • Carotid sinus massage (with caution in elderly or those with cardiovascular disease) 4
   • Stimulation of the ear/auditory canal 4

2. Respiratory pattern disruption:

   • Breathing into a paper bag (creates transient hypercapnia)
   • Drinking cold water rapidly 4

First-Line Pharmacological Treatment

• Chlorpromazine: 25-50 mg orally three to four times daily 1
  • FDA-approved specifically for intractable hiccups
  • May cause sedation, hypotension, and extrapyramidal side effects

Second-Line Pharmacological Options

• Baclofen: GABA-B receptor agonist that reduces neuronal excitability 2, 6
• Gabapentin: reduces neuronal excitability through calcium channel modulation 2
• Metoclopramide: prokinetic agent that may help when hiccups are related to gastric distention or GERD 7, 6
• Lidocaine: can be used intravenously in hospital settings for refractory cases 2

Interventional Approaches for Intractable Cases

• Phrenic nerve block or surgical intervention 6
• Vagus nerve stimulation (VNS): emerging therapy for medically refractory cases 6
• Acupuncture: may be effective in some cases, though evidence is limited 2, 6

Special Considerations

• Identify and treat underlying causes, which may include:

  • Central nervous system disorders (stroke, tumors)
  • Thoracic disorders (pneumonia, myocardial ischemia)
  • Gastrointestinal disorders (GERD, gastric distention)
  • Metabolic disorders (uremia, electrolyte imbalances)
  • Medication side effects (steroids, benzodiazepines, chemotherapy) 2

• For hiccups during anesthesia or in the perioperative period:

  • Consider propofol (1-2 mg/kg IV) if hiccups occur during airway management 3
  • Ensure proper depth of anesthesia before airway manipulation 3

Common Pitfalls and Caveats

• Failure to identify and address underlying causes may lead to recurrence

• Chlorpromazine should be used with caution in elderly patients due to increased risk of hypotension and neuromuscular reactions 1

• For elderly patients, start with lower doses of chlorpromazine and titrate gradually 1

• Persistent hiccups can lead to significant complications including:

  • Malnutrition and weight loss
  • Sleep disturbances
  • Fatigue and exhaustion
  • Psychological distress 6

• Do not underestimate the impact of prolonged hiccups on quality of life; they can cause considerable physical and psychological morbidity 6