Medications for Treating Hiccups
Chlorpromazine is the only FDA-approved medication for treating hiccups, with a recommended dosage of 25-50 mg orally three to four times daily for adults. 1
First-Line Treatment Options
- Chlorpromazine (Thorazine) is the first-line treatment for intractable hiccups, with FDA approval specifically for this indication 1, 2
- For adults, the typical dosage is 25-50 mg orally three to four times daily as needed 1
- If symptoms persist for 2-3 days, parenteral therapy may be indicated 1
Second-Line Treatment Options
- Baclofen is recommended as an effective alternative with a starting dose of 5-10 mg three times daily 3, 4
- Metoclopramide 10-20 mg orally or IV every 4-6 hours has shown efficacy in treating persistent hiccups 3, 5
- Gabapentin has demonstrated effectiveness and favorable tolerability at modest doses for hiccup management in rehabilitation patients 6
Other Pharmacological Options
- Haloperidol can be used at low doses (0.5-2 mg) as an alternative antipsychotic with antiemetic and anti-hiccup properties 7, 4
- Amitriptyline, midazolam, nifedipine, nimodipine, orphenadrine, and valproic acid have been reported as successful treatments in case reports 8
- Benzodiazepines such as lorazepam (0.5-2 mg every 4-6 hours) may be helpful, especially when anxiety is a contributing factor 9, 7
Mechanism of Action
- Chlorpromazine works primarily as a dopamine antagonist, affecting the central hiccup center 2, 4
- Baclofen, a GABA-B receptor agonist, helps reduce hiccups by decreasing excitatory neurotransmission in the hiccup reflex arc 4, 5
- Metoclopramide has both central dopamine antagonist effects and peripheral prokinetic actions that may help resolve hiccups 3, 5
Special Considerations
- Monitor for extrapyramidal symptoms with chlorpromazine and other antipsychotics 10
- Benztropine can be used to treat extrapyramidal side effects if they occur 10
- Elderly patients should receive lower doses of chlorpromazine as they are more susceptible to hypotension and neuromuscular reactions 1
- For patients with liver disease, avoid prochlorperazine due to increased risk of extrapyramidal symptoms 7
Treatment Algorithm
- Begin with chlorpromazine 25-50 mg orally three to four times daily 1
- If ineffective after 2-3 days or not tolerated, switch to baclofen 5-10 mg three times daily 3, 4
- For patients who cannot tolerate chlorpromazine or baclofen, try gabapentin at modest doses 6
- For patients with anxiety-related hiccups, consider adding lorazepam 0.5-2 mg every 4-6 hours 9, 7
- For refractory cases, consider combination therapy or consultation with specialists 8, 4
Common Pitfalls to Avoid
- Failing to investigate underlying causes of persistent hiccups (such as gastroesophageal reflux, myocardial infarction, brain tumors, or renal failure) 4, 5
- Overlooking drug-induced hiccups, which may require discontinuation of the offending agent 9
- Not monitoring for sedation when using chlorpromazine, especially in elderly patients 3, 1
- Underestimating the potential for QT prolongation with medications like chlorpromazine 3