What are the treatment options for hiccups?

Treatment Options for Hiccups

Chlorpromazine is the only FDA-approved medication for intractable hiccups, with a recommended dosage of 25-50 mg three to four times daily. 1

Non-pharmacological Interventions (First-Line)

For brief, self-limited hiccups, try these physical maneuvers before moving to medications:

• Physical maneuvers that stimulate the vagus nerve, such as Larson's maneuver 2
• Techniques that disrupt diaphragmatic rhythm 3
• Stimulation of the uvula or pharynx 3
• Breath-holding techniques 4

Pharmacological Treatments

For Intractable Hiccups (Persisting >48 hours)

1. First-line medication:

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

2. Alternative medications with evidence of efficacy:

   • Baclofen: Has been studied in randomized controlled trials 6, 7
   • Metoclopramide: Has been studied in randomized controlled trials 6, 7
   • Gabapentin: Studied prospectively and may be better tolerated than chlorpromazine in rehabilitation patients 6, 8

3. Other pharmacological options:

   • Haloperidol 6
   • Amitriptyline 6
   • Nifedipine/Nimodipine 6
   • Valproic acid 6
   • Midazolam 6
   • Orphenadrine 6

For Perioperative Hiccups

• Propofol (1-2 mg/kg IV) can be considered during anesthesia or in the perioperative period 2

Treatment Algorithm

1. For brief hiccups (<48 hours):

   • Start with non-pharmacological interventions
   • If persistent, consider chlorpromazine

2. For persistent hiccups (>48 hours but <2 months):

   • Identify and treat underlying cause if possible
   • Start chlorpromazine 25-50 mg TID or QID 1
   • If ineffective or poorly tolerated, switch to baclofen or gabapentin 6, 7

3. For intractable hiccups (>2 months):

   • Comprehensive workup for underlying causes (GI, CNS, thoracic, metabolic) 4, 7
   • Consider combination therapy
   • Consider nerve blockade, pacing, or acupuncture if pharmacotherapy fails 4

Important Considerations

• Untreated persistent hiccups can lead to significant complications:

  • Weight loss 5
  • Depression 5
  • Sleep deprivation 7

• When using chlorpromazine:

  • Lower dosages are generally sufficient for elderly patients 1
  • Monitor for hypotension and sedation 5
  • Avoid concurrent use with other dopamine blockers (metoclopramide, phenothiazines, haloperidol) due to risk of excessive dopamine blockade 9

• Common underlying conditions to investigate:

  • Gastroesophageal reflux disease 4, 7
  • Central nervous system disorders (brain tumors, traumatic brain injury) 5
  • Myocardial ischemia 4
  • Metabolic disorders 4

• Upper gastrointestinal investigations (endoscopy, pH monitoring, manometry) should be included in the diagnostic evaluation of chronic hiccups 7