What is the treatment for hiccups?

Treatment of Hiccups

For intractable hiccups lasting more than 48 hours, chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved first-line pharmacological treatment, with the option to escalate if symptoms persist for 2-3 days. 1

Initial Approach: Non-Pharmacological Interventions

For acute hiccups (< 48 hours), begin with physical maneuvers before considering medications:

• Vagal stimulation techniques such as Larson's maneuver (applying deep pressure in the "laryngospasm notch" between the posterior mandible and mastoid process while performing jaw thrust) can effectively terminate hiccups 2
• Other vagal maneuvers include stimulating the uvula or pharynx, which may disrupt the hiccup reflex arc 3
• Measures that disrupt diaphragmatic rhythm or respiratory patterns are simple first-line interventions 3

Important caveat: Most acute hiccup episodes resolve spontaneously within minutes and rarely require medical intervention 4. However, if hiccups persist beyond 48 hours (persistent hiccups) or beyond 2 months (intractable hiccups), they warrant thorough evaluation and treatment 5, 6.

Pharmacological Treatment Algorithm

First-Line: Chlorpromazine (FDA-Approved)

Chlorpromazine is the only FDA-approved medication specifically indicated for intractable hiccups 1:

• Dosing: 25-50 mg orally three to four times daily 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration is indicated 1
• This remains the most widely employed agent with established efficacy 3, 6

Alternative Pharmacological Options

When chlorpromazine is contraindicated or ineffective, consider:

• Metoclopramide: A prokinetic agent that is widely employed for persistent hiccups 3, 6
• Baclofen: Has emerged as a safe and often effective treatment, particularly useful in chronic cases 6
• Gabapentin: Effective pharmacotherapy option acting on the reflex arc 5

Perioperative/Anesthesia Setting

• Propofol 1-2 mg/kg IV can be considered for hiccups during anesthesia or in the perioperative period, ensuring proper depth of anesthesia before airway manipulation 2

Diagnostic Considerations Before Treatment

Critical warning: Persistent or intractable hiccups can indicate serious underlying pathology and should not be dismissed 4. Look for:

• Gastrointestinal causes: Gastric distention (most common), gastroesophageal reflux, gastritis, peptic ulcer disease—upper GI endoscopy, pH monitoring, and manometry should be systematically included 6
• Neurological causes: Stroke, space-occupying lesions, brain injury 5
• Cardiovascular causes: Myocardial infarction, myocardial ischemia 5, 6
• Thoracic causes: Tumors, herpes infection 5
• Metabolic causes: Renal failure 6
• Drug-induced: Anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy 5

Treatment Escalation for Refractory Cases

If standard pharmacotherapy fails:

• Nerve blockade: Physical disruption of the phrenic nerve 3
• Pacing techniques 5
• Acupuncture 3, 5
• Surgical intervention: Very rarely required but may be necessary for intractable cases 4

Common Pitfalls to Avoid

• Do not dismiss persistent hiccups (>48 hours) as benign—they affect 1-30% of certain patient populations and can cause depression, weight loss, and sleep deprivation 6
• Do not overlook gastric distention and GERD—these are the most commonly identifiable causes after acute episodes and should be systematically investigated 6, 4
• Do not use chlorpromazine in pediatric patients under 6 months except where potentially lifesaving 1
• Monitor for chlorpromazine side effects: Hypotension and dystonic reactions may occur; repeated doses can prolong QT interval and precipitate torsades de pointes 7