Treatment for Acute Hiccups
For acute hiccups, first-line treatments include physical maneuvers to disrupt diaphragmatic rhythm, followed by pharmacological therapy with chlorpromazine 25-50 mg three to four times daily if symptoms persist beyond 48 hours. 1
Physical Maneuvers (First-Line)
- Simple physical maneuvers should be attempted first as they often terminate benign, self-limited hiccups 2:
- Breath holding techniques
- Drinking water rapidly or from the opposite side of a glass
- Stimulation of the uvula or pharynx
- Larson's maneuver (applying pressure at the "laryngospasm notch" between the posterior border of the mandible and mastoid process) for severe cases 3
Addressing Underlying Causes
- Identify and treat common triggers 3, 4:
- Avoid alcohol and spicy foods that may cause gastroesophageal reflux
- Consider anti-reflux therapy as an empirical trial
- Address gastric distension (most common identifiable cause) 5
Pharmacological Treatment
- If hiccups persist beyond 48 hours or are particularly distressing, medication should be considered 5:
- Chlorpromazine: 25-50 mg three to four times daily (FDA-approved for intractable hiccups) 1
- Metoclopramide: Supported by small randomized controlled trials for peripheral causes of hiccups 6, 7
- Baclofen: First choice for central causes of hiccups based on limited controlled trials 6, 7
- Gabapentin: Alternative first-line option with fewer side effects than neuroleptics for persistent cases 6
Monitoring and Escalation
- Monitor for respiratory complications, especially in patients approaching 48 hours of continuous hiccups 8
- For severe cases with respiratory compromise 3:
- Apply continuous positive airway pressure with 100% oxygen
- Consider propofol 1-2 mg/kg IV if oxygen saturation is falling
- Watch for signs of post-obstructive pulmonary edema
Special Considerations
- Persistent hiccups (>48 hours) or intractable hiccups (>2 months) may indicate serious underlying pathology requiring thorough investigation 4, 5
- In palliative care patients, midazolam may be useful for terminal cases unresponsive to other treatments 7
- For truly refractory cases, consider interventional procedures such as nerve blockade 7
Common Pitfalls
- Failing to identify and address underlying causes before starting symptomatic treatment 4
- Using neuroleptics like chlorpromazine for long-term management without considering their side effect profile 6
- Overlooking the distinction between central and peripheral causes, which respond differently to medications 7