Treatment for Hiccups
For intractable hiccups, chlorpromazine 25-50 mg three to four times daily is the FDA-approved first-line pharmacological treatment, though simple physical maneuvers should be attempted first for acute episodes. 1
Initial Management Approach
Non-Pharmacological Interventions (First-Line for Acute Hiccups)
Simple physical maneuvers that stimulate the pharynx or disrupt respiratory rhythm should be tried initially: 2
Hiccup relief using Active Prolonged Inspiration (HAPI) technique: Inspire maximally, then continue attempting to inspire with an open glottis for 30 seconds total, followed by slow expiration - this showed immediate relief in 21/21 patients in a recent study 3
Larson's maneuver adaptation: Apply deep pressure between the posterior border of the mandible and mastoid process, which can terminate hiccups 4
Pharyngeal stimulation: Measures that stimulate the uvula or pharynx may help speed resolution of benign, self-limited hiccups 2
When to Escalate to Pharmacological Treatment
If hiccups persist beyond 48 hours (persistent hiccups) or 2 months (intractable hiccups), pharmacological intervention becomes necessary: 5
Pharmacological Management
First-Line Medication
Chlorpromazine is the primary FDA-approved drug for intractable hiccups: 1
- Dosing: 25-50 mg orally three to four times daily 1
- Duration: If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated 1
- Important warnings: Can cause hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 6
Alternative Pharmacological Options
If chlorpromazine is contraindicated or ineffective, consider: 2, 5
- Metoclopramide: Widely employed alternative agent 2
- Gabapentin: Effective pharmacotherapy option 5
- Baclofen: Another validated treatment 5
- Proton pump inhibitors (PPIs): Should be first-line when GERD is suspected as the underlying cause, as GERD is the most common etiology of persistent hiccups 7
Special Situation: Anesthesia-Related Hiccups
For hiccups occurring during or after anesthesia: 4
- Propofol 1-2 mg/kg IV may be effective 4
- Apply continuous positive airway pressure with 100% oxygen if associated with laryngospasm 4
Underlying Cause Investigation
Persistent hiccups warrant evaluation for underlying pathology: 6, 7
- Central nervous system causes: Brain tumors, traumatic brain injury, stroke, space-occupying lesions 6, 5
- Peripheral causes: Gastroesophageal reflux disease (most common), myocardial ischemia, tumors along the reflex arc, herpes infection 5, 7
- Medication-induced: Anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy 5
Appropriate gastrointestinal consultation should be obtained given GERD is the most common cause 7
Clinical Consequences of Untreated Persistent Hiccups
Failure to treat persistent hiccups can lead to: 6
Refractory Cases
For severe intractable cases unresponsive to pharmacotherapy: 2, 5