What causes frequent hiccups?

Causes of Frequent Hiccups

Gastroesophageal reflux disease (GERD) is the most common cause of frequent hiccups and should be considered as the primary etiology in patients with persistent hiccups. 1, 2

Common Causes of Hiccups

• Gastrointestinal disorders:

  • Gastroesophageal reflux disease (GERD) - most common identifiable cause 1, 2
  • Gastritis 3
  • Overdistension of the stomach 3
  • Hiatal hernia 4

• Central nervous system disorders:

  • Stroke 4
  • Space-occupying lesions (tumors) 4
  • Brain injury 4
  • Multiple sclerosis 4

• Irritation of the vagus or phrenic nerve:

  • Myocardial ischemia 4
  • Herpes zoster infection 4
  • Neck tumors 4

• Metabolic disorders:

  • Uremia 3
  • Electrolyte imbalances 3

• Medication-induced:

  • Anti-Parkinson drugs 4
  • Anesthetic agents 4
  • Steroids 4
  • Chemotherapeutic agents 4

• Psychogenic factors:

  • Anxiety disorders 5
  • Stress 5

Pathophysiology of Hiccups

Hiccups result from a complex reflex arc involving:

• Afferent limb: Vagus nerve, phrenic nerve, and sympathetic chain (T6-T12) 4
• Central processor: Medulla oblongata with connections to the midbrain 4
• Efferent limb: Phrenic nerve to diaphragm, recurrent laryngeal nerve to glottis 4

Any irritation or disruption along this pathway can trigger hiccups 4.

Classification of Hiccups Based on Duration

• Acute hiccups: Episodes lasting less than 48 hours 3
• Persistent hiccups: Episodes lasting more than 48 hours but less than 2 months 4
• Intractable hiccups: Episodes lasting more than 2 months 4

Diagnostic Approach for Persistent Hiccups

For patients with frequent or persistent hiccups, the following diagnostic workup should be considered:

• Detailed history: Focus on medication use, recent procedures, and gastrointestinal symptoms 3
• Physical examination: Evaluate for abdominal distension, masses, or neurological abnormalities 3
• Endoscopy: To evaluate for GERD, which is the most common cause 2
• Imaging studies: CT or MRI of brain/chest/abdomen if central causes are suspected 4

Treatment Options

First-line treatment should target the underlying cause:

• For GERD-related hiccups: Proton pump inhibitors (PPIs) are the first-line therapy 1, 2
• For medication-induced hiccups: Discontinue the offending agent if possible 4

For symptomatic management:

• Pharmacologic options:

  • Metoclopramide: Particularly effective when hiccups are associated with gastrointestinal disorders 6
  • Gabapentin: Alternative option with evidence of efficacy 6
  • Baclofen: Acts on the central nervous system 4
  • Chlorpromazine: Traditional treatment for persistent hiccups 4

• Non-pharmacologic approaches:

  • Nerve blockade 4
  • Breathing techniques (breath holding, breathing into a paper bag) 4
  • Acupuncture 4

Important Considerations

• Persistent hiccups (>48 hours) should never be dismissed as they may indicate serious underlying pathology 3
• When using metoclopramide, be aware of FDA warnings about serious adverse effects with prolonged use (>12 weeks), including risk of tardive dyskinesia 6
• In cases where first-line therapy with PPIs fails, consider central causes and expand the diagnostic workup 1

Remember that while most hiccup episodes are self-limiting, persistent hiccups significantly impact quality of life and require thorough evaluation and targeted treatment 3.