Management of Hiccups
For intractable hiccups, chlorpromazine 25-50 mg three to four times daily is the first-line pharmacological treatment, as it remains the only FDA-approved medication for this indication. 1, 2
Initial Assessment and Classification
Hiccups should be classified by duration to guide management:
- Acute hiccups: Less than 48 hours - usually self-limited and benign 3
- Persistent hiccups: 48 hours to 2 months 4
- Intractable hiccups: Longer than 2 months 4
Stepwise Management Approach
Step 1: Non-Pharmacological Interventions
For acute hiccups, attempt physical maneuvers first:
- Vagal stimulation techniques: Breath-holding, Valsalva maneuver, or drinking cold water 5
- Pharyngeal stimulation: Stimulating the uvula or pharynx 5
- Larson's maneuver: Applying pressure between the posterior border of the mandible and mastoid process can terminate hiccups 6
- Tongue traction: Pulling the tongue forward to stimulate the vagus nerve 7
These maneuvers work by disrupting the diaphragmatic rhythm or stimulating components of the hiccup reflex arc. 5
Step 2: Identify and Treat Underlying Causes
Look for reversible causes along the hiccup reflex arc:
- Gastric causes: Gastric distention (most common), gastroesophageal reflux, gastritis, peptic ulcer disease 8, 3
- Central causes: Stroke, brain tumors, CNS injury 4
- Peripheral causes: Myocardial infarction, phrenic nerve irritation, diaphragmatic irritation, mediastinal tumors 4, 8
- Metabolic causes: Renal failure, electrolyte abnormalities 8
- Medication-induced: Anti-Parkinson drugs, anesthetic agents, steroids, chemotherapy 4
Upper gastrointestinal investigations (endoscopy, pH monitoring) should be included systematically in persistent cases, as gastric and duodenal pathology is commonly observed. 8
Step 3: Pharmacological Treatment
For intractable hiccups (>48 hours):
First-Line: Chlorpromazine
- Dosing: 25-50 mg orally three to four times daily 1, 2
- If oral therapy fails after 2-3 days, give 25-50 mg intramuscularly 2
- For severe cases, use slow IV infusion: 25-50 mg in 500-1000 mL saline with patient flat in bed 2
- Critical monitoring: Watch for sedation, hypotension, and extrapyramidal symptoms 7
- Chlorpromazine is the only FDA-approved medication specifically indicated for intractable hiccups 2
Alternative Pharmacological Options
The choice depends on the suspected etiology:
For central causes (CNS pathology):
For peripheral causes (GI or phrenic nerve irritation):
- Metoclopramide: Recommended as first choice for peripheral causes 5, 9
- Demulcents: Simple linctus syrup can be tried initially 7
For cancer patients:
- Consider opioid rotation if patient is on opioids, as some opioids may trigger hiccups 7
- Midazolam may be useful in terminal illness 9
During anesthesia or post-extubation:
- Propofol 1-2 mg/kg IV may be effective 6
Step 4: Refractory Cases
For patients who fail pharmacological management:
- Interventional procedures: Vagal or phrenic nerve block or stimulation should be considered 9
- Physical disruption: Phrenic nerve procedures 5
- Alternative approaches: Acupuncture, hypnosis (though evidence is largely anecdotal) 5, 4
Special Considerations and Pitfalls
Common pitfalls to avoid:
- Do not dismiss persistent hiccups as benign - they can indicate serious underlying pathology including myocardial infarction, brain tumors, or malignancy 8
- Persistent hiccups can cause significant morbidity including depression, weight loss, and sleep deprivation 8
- When using chlorpromazine parenterally, keep patient lying down for at least 30 minutes after injection due to hypotensive effects 2
- Avoid subcutaneous injection of chlorpromazine and never inject undiluted into a vein 2
Elderly patients require special attention:
- Use lower dosages as they are more susceptible to hypotension and neuromuscular reactions 1, 2
- Increase dosage more gradually 1
Pediatric considerations: