What is the treatment for acute hiccups?

Treatment for Acute Hiccups

For acute hiccups, first-line treatment includes physical maneuvers to disrupt the hiccup reflex, followed by pharmacological therapy with chlorpromazine 25-50 mg three to four times daily if physical interventions fail. 1, 2

Physical Maneuvers (First-Line)

Physical interventions aim to interrupt the hiccup reflex arc and should be attempted before moving to medications:

• Stimulation of the uvula or pharynx by:

  • Drinking water rapidly from the opposite side of a glass 2
  • Swallowing granulated sugar 3
  • Gargling with cold water 2, 4

• Disruption of diaphragmatic rhythm by:

  • Breath holding for as long as possible 2, 4
  • Breathing into a paper bag (rebreathing CO2) 3, 4
  • Pulling knees to chest to compress the diaphragm 2, 5

• Vagal stimulation techniques:

  • Carotid massage (only if no contraindications) 3
  • Valsalva maneuver (bearing down against a closed glottis) 3, 4

Pharmacological Treatment (Second-Line)

If physical maneuvers fail after 1-2 hours of persistent hiccups, medication therapy should be initiated:

• First-line medication: Chlorpromazine 25-50 mg orally three to four times daily 1

  • FDA-approved specifically for intractable hiccups
  • Dosing should be adjusted based on response and tolerability
  • Monitor for potential side effects including sedation and hypotension

• Alternative medications if chlorpromazine is contraindicated or ineffective:

  • Metoclopramide: Effective for hiccups related to gastric distention or reflux 5, 6
  • Baclofen: Supported by small randomized controlled trials 6
  • Gabapentin: Effective with fewer side effects during long-term use 6

Addressing Underlying Causes

Identify and treat common underlying causes of acute hiccups:

• Gastric distention: Most common cause of acute hiccups 4

  • Avoid rapid eating and carbonated beverages
  • Small, frequent meals rather than large meals

• Gastroesophageal reflux: Second most common cause 4

  • Consider empiric trial of anti-reflux therapy
  • Avoid alcohol and spicy foods

Special Considerations

• If hiccups persist beyond 48 hours despite treatment, they are classified as persistent hiccups and require more thorough investigation 3, 4

• Monitor for respiratory complications in prolonged hiccups, including potential for respiratory distress or laryngospasm which can lead to post-obstructive pulmonary edema 7

• For severe cases with respiratory compromise, follow laryngospasm treatment protocol:

  • Apply continuous positive airway pressure with 100% oxygen 8
  • Consider Larson's maneuver (pressure at the "laryngospasm notch") 8
  • For persistent cases with oxygen desaturation, propofol 1-2 mg/kg IV may be needed 8

Treatment Algorithm

1. Begin with physical maneuvers for 1-2 hours
2. If unsuccessful, initiate chlorpromazine 25-50 mg orally three to four times daily
3. If no response within 24-48 hours, consider alternative medications
4. If hiccups persist >48 hours, investigate for underlying pathology
5. Monitor for respiratory complications throughout treatment

Remember that while most acute hiccups are self-limiting and benign, persistent or intractable hiccups may indicate serious underlying pathology and warrant thorough investigation 4, 6.