What medications are used to treat hiccups?

Medications for Treating Hiccups

Chlorpromazine is the first-line medication for treating persistent or intractable hiccups, as it is the only FDA-approved drug specifically for this indication. 1, 2, 3

First-Line Pharmacological Options

• Chlorpromazine (Thorazine):
  • Dosage: 25-50 mg orally three to four times daily for adults 1
  • For intractable cases, can be administered intramuscularly (25-50 mg) or intravenously (25-50 mg diluted in saline) 2
  • Mechanism: Acts as a dopamine antagonist with additional anticholinergic and antihistaminic properties 3
  • Side effects: Sedation, hypotension, extrapyramidal symptoms 1, 2

Second-Line Pharmacological Options

• Metoclopramide:

  • Effective for hiccups related to gastric distention or gastroesophageal reflux 4
  • Mechanism: Prokinetic agent that increases lower esophageal sphincter tone 3
  • Caution: Risk of extrapyramidal symptoms, especially with prolonged use 5

• Baclofen:

  • Dosage: Starting at 5-10 mg three times daily, can be increased gradually 6, 4
  • Mechanism: GABA-B receptor agonist that may decrease diaphragmatic excitability 4
  • Evidence: Has emerged as a safe and often effective treatment in recent studies 4

• Gabapentin:

  • Dosage: Starting at modest doses (300-900 mg daily in divided doses) 7
  • Particularly useful in rehabilitation settings where chlorpromazine may not be well-tolerated 7
  • Favorable side effect profile compared to traditional neuroleptics 7

Other Pharmacological Options

• Haloperidol: Alternative antipsychotic for patients who cannot tolerate chlorpromazine 3
• Amitriptyline: May be effective for neuropathic causes of hiccups 3
• Nifedipine/Nimodipine: Calcium channel blockers that may help in certain cases 3
• Valproic acid: Can be considered for hiccups of central nervous system origin 3
• Midazolam: For short-term management in acute settings 3
• Olanzapine: Atypical antipsychotic with antiemetic properties that may help with hiccups 8

Non-Pharmacological Approaches

• Physical maneuvers that stimulate the uvula or pharynx:

  • Drinking water from the opposite side of a glass
  • Swallowing granulated sugar
  • Breathing into a paper bag
  • These methods may help terminate benign, self-limited hiccups 9

• For refractory cases:

  • Phrenic nerve block
  • Acupuncture
  • Hypnosis 9, 6

Treatment Algorithm

1. For brief, self-limited hiccups:

   • Physical maneuvers as first approach 9
   • If unsuccessful after 48 hours, consider pharmacological intervention

2. For persistent hiccups (>48 hours):

   • Start with chlorpromazine 25 mg orally three times daily 1
   • If ineffective or poorly tolerated, switch to baclofen or gabapentin 4, 7

3. For intractable hiccups (>2 months):

   • Comprehensive evaluation for underlying causes (gastroesophageal reflux, CNS disorders, thoracic lesions) 6
   • Consider combination therapy or specialist referral 3

Important Considerations

• Elderly patients are more susceptible to hypotension and extrapyramidal side effects from chlorpromazine; lower doses are recommended 1, 2
• Persistent hiccups can lead to significant complications including weight loss, sleep deprivation, and depression 4
• Gastroesophageal reflux disease is a common cause of persistent hiccups and should be treated concurrently 4
• When using chlorpromazine intravenously, administer slowly and monitor for hypotension 2