Treatment of Hiccups
For intractable hiccups lasting more than 48 hours, chlorpromazine 25-50 mg three to four times daily is the FDA-approved first-line pharmacological treatment, while acute self-limited hiccups often respond to simple physical maneuvers. 1
Acute Hiccups (< 48 hours)
Non-Pharmacological Maneuvers
- Physical maneuvers that stimulate the pharynx or disrupt respiratory rhythm should be attempted first, as most acute hiccups are self-limited and resolve spontaneously within minutes 2, 3
- Applying deep pressure between the posterior border of the mandible and mastoid process (similar to Larson's maneuver) can terminate hiccups 4
- Measures that stimulate the uvula or pharynx are simple and often effective 2
- Maneuvers that disrupt diaphragmatic rhythm may speed resolution 2
When to Escalate Treatment
- Medical intervention is rarely needed for acute hiccups unless they are particularly bothersome to the patient 3
- Most episodes resolve within minutes without any intervention 3
Persistent Hiccups (48 hours to 2 months)
Initial Pharmacological Approach
- Chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved treatment for intractable hiccups 1
- If symptoms persist for 2-3 days on oral therapy, parenteral administration should be considered 1
- Metoclopramide is another widely employed agent, particularly when gastroesophageal reflux or gastric distention is suspected 2, 5
Alternative Pharmacological Options
- Baclofen has emerged as a safe and often effective treatment, particularly when chlorpromazine is contraindicated or ineffective 5
- Gabapentin is another pharmacological option for persistent cases 6
- Other agents include serotonergic agonists, prokinetics, and lidocaine 6
Intractable Hiccups (> 2 months)
Diagnostic Considerations
- A focused evaluation is essential as intractable hiccups can indicate serious underlying pathology including myocardial infarction, brain tumors, renal failure, or malignancy 5, 3
- Upper gastrointestinal investigations (endoscopy, pH monitoring) should be included systematically, as gastric/duodenal ulcers, gastritis, and esophageal reflux are commonly observed 5
- Central causes (stroke, space-occupying lesions) and peripheral causes (tumors along the reflex arc, myocardial ischemia) must be considered 6
Treatment Hierarchy
- Treat the underlying cause when identified - this is the most effective approach 3
- Chlorpromazine remains the primary pharmacological agent, with dosing potentially increased gradually in severe cases 1
- Non-pharmacological interventions include nerve blockade, pacing, and acupuncture for refractory cases 6
- Physical disruption of the phrenic nerve, hypnosis, or surgical intervention are reserved for the most severe cases 2
Special Populations and Contexts
Perioperative/Anesthesia Setting
- For hiccups occurring during anesthesia or post-extubation, propofol 1-2 mg/kg IV may be effective 4
- Continuous positive airway pressure with 100% oxygen while maintaining airway patency should be applied 4
- Avoid unnecessary airway stimulation 4
Pediatric Patients (6 months to 12 years)
- Chlorpromazine dosing is ¼ mg/lb body weight every 4-6 hours as needed 1
- The medication should generally not be used in children under 6 months except in potentially life-saving situations 1
Critical Pitfalls to Avoid
- Do not dismiss persistent or intractable hiccups as benign - they can be harbingers of serious medical pathology requiring thorough investigation 5, 3
- Do not delay diagnostic workup in persistent cases - the underlying etiology may be life-threatening (myocardial infarction, brain tumor, etc.) 5
- Recognize that gastric overdistension is the most common identifiable cause in acute cases, followed by gastroesophageal reflux 3
- Be aware that various medications (anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy) can cause hiccups 6
- Intractable hiccups can lead to serious consequences including depression, weight loss, and sleep deprivation if left untreated 5