What are the treatment options for hiccups?

Treatment Options for Hiccups

Chlorpromazine (25-50 mg three to four times daily) is the first-line medication for intractable hiccups, as it is FDA-approved specifically for this indication. 1

Understanding Hiccups

Hiccups are sudden, involuntary contractions of the diaphragm and intercostal muscles followed by immediate laryngeal closure, producing the characteristic "hic" sound. 2

• Hiccups are classified based on duration:
  • Brief/acute: Self-limited episodes (most common)
  • Persistent: Episodes lasting more than 48 hours
  • Intractable: Episodes lasting more than 2 months 2

First-Line Physical Interventions

For brief episodes of hiccups, try these non-pharmacological approaches first:

• Stimulation of the pharynx or uvula (such as drinking water quickly) 3
• Disruption of respiratory rhythm (breath holding, Valsalva maneuver) 3
• Physical maneuvers that interrupt the hiccup reflex arc 4

Pharmacological Treatment Algorithm

First-Line Medication

• Chlorpromazine: 25-50 mg orally three to four times daily
  • FDA-approved specifically for intractable hiccups
  • Can be continued until symptoms resolve 1

Alternative Medications (if chlorpromazine fails or is contraindicated)

For hiccups with central causes (brain lesions, stroke, etc.):

• Baclofen: First choice for centrally-mediated hiccups 5, 4

For hiccups with peripheral causes (gastroesophageal, phrenic nerve irritation):

• Metoclopramide: First choice for peripherally-mediated hiccups 4
• Gabapentin: Effective alternative for neuropathic causes 2

For palliative care patients with terminal illness:

• Midazolam: May be useful when other treatments fail 4

Addressing Underlying Causes

Hiccups often result from specific underlying conditions that should be identified and treated:

• Gastrointestinal causes:

  • Gastroesophageal reflux disease (GERD)
  • Gastritis
  • Gastric or duodenal ulcers 5

• Central nervous system causes:

  • Stroke
  • Brain tumors
  • Traumatic brain injury 2, 5

• Other medical conditions:

  • Myocardial ischemia
  • Renal failure
  • Infections (particularly herpes zoster) 2

Interventional Procedures for Refractory Cases

When medications fail to control intractable hiccups, consider:

• Nerve blocks (phrenic or vagal) 4
• Nerve stimulation techniques 4
• Acupuncture 2

Important Considerations and Precautions

• Monitor for side effects of chlorpromazine, including:

  • Hypotension
  • Sedation
  • Extrapyramidal symptoms 6
  • QT interval prolongation 6

• Elderly patients should receive lower doses of medications due to increased susceptibility to side effects 1

• Persistent hiccups can lead to serious consequences if untreated:

  • Sleep deprivation
  • Weight loss
  • Depression
  • Decreased quality of life 5, 4