What are the treatment options for hiccups?

Treatment Options for Hiccups

Chlorpromazine is the most effective first-line pharmacological treatment for intractable hiccups, with a recommended dose of 25-50 mg three to four times daily for adults. 1

Understanding Hiccups

Hiccups are sudden, involuntary contractions of the diaphragm and intercostal muscles followed by laryngeal closure, producing the characteristic "hic" sound. They can be categorized based on duration:

• Acute hiccups: Self-limited episodes lasting less than 48 hours 2
• Persistent hiccups: Episodes lasting more than 48 hours 2
• Intractable hiccups: Episodes lasting more than 2 months 2

Treatment Algorithm

Step 1: Non-pharmacological Interventions

Try these simple physical maneuvers first for acute hiccups:

• Vagal nerve stimulation techniques:
  • Larson's maneuver: Apply pressure between the posterior border of the mandible and mastoid process while performing a jaw thrust 3
  • Breath holding or breathing into a paper bag 4
  • Drinking cold water rapidly or gargling with ice water 4
  • Swallowing dry bread or granulated sugar 4

Step 2: Pharmacological Interventions for Persistent/Intractable Hiccups

First-line:

• Chlorpromazine: 25-50 mg orally three to four times daily 1
  • FDA-approved specifically for intractable hiccups
  • Caution: May cause hypotension, sedation, extrapyramidal symptoms, and QT prolongation 5

Alternative medications if chlorpromazine fails or is contraindicated:

• Baclofen: Emerging as a safe and effective treatment 6
• Gabapentin: Effective for neurologically-mediated hiccups 2
• Metoclopramide: Particularly useful when GI disorders are suspected 4, 6
• Lidocaine: Can be used in refractory cases 2

Step 3: Interventional Approaches for Refractory Cases

• Nerve blocks (phrenic nerve) 2
• Acupuncture 2
• Intradermal injections: A mixture of thiocolchicoside and lidocaine injected intradermally at the epigastric region has shown success in emergency settings 7

Special Considerations

Perioperative Hiccups

• Propofol (1-2 mg/kg IV) can be effective for hiccups during anesthesia 3
• Ensure proper depth of anesthesia before airway manipulation to prevent laryngospasm 3

Underlying Causes to Investigate

When hiccups persist, investigate for:

• Central nervous system causes: Stroke, brain tumors, traumatic brain injury 5
• Gastrointestinal disorders: GERD, gastritis, peptic ulcers (most common) 6
• Thoracic disorders: Myocardial infarction, pericarditis 6
• Metabolic disorders: Uremia, electrolyte imbalances 2
• Medication-induced: Steroids, benzodiazepines, anesthetics 2

Complications of Untreated Persistent Hiccups

• Weight loss 5
• Depression 5
• Sleep deprivation 6
• Fatigue 7

Pitfalls and Caveats

• Always rule out serious underlying conditions before attributing hiccups to benign causes 2
• Chlorpromazine, while effective, requires monitoring for adverse effects, especially in elderly patients 1
• For pediatric patients under 12 years, dosing should be adjusted by weight (¼ mg/lb body weight every 4-6 hours) 1
• Persistent hiccups warrant comprehensive gastrointestinal evaluation including endoscopy, pH monitoring, and manometry 6