How to stop hiccups?

How to Stop Hiccups

For acute, self-limited hiccups, start with simple physical maneuvers that stimulate the vagus nerve or disrupt diaphragmatic rhythm; if hiccups persist beyond 48 hours or become intractable, pharmacological treatment with chlorpromazine is the FDA-approved first-line therapy.

Immediate Non-Pharmacological Interventions

Simple Physical Maneuvers (First-Line for Acute Hiccups)

• Apply firm pressure between the posterior border of the mandible and mastoid process (similar to Larson's maneuver), which can terminate hiccups immediately 1
• Perform the HAPI (Hiccup relief using Active Prolonged Inspiration) 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 all 21 patients studied 2
• Vagal maneuvers are effective for acute hiccups and include: stimulation of the uvula/pharynx, carotid sinus massage, Valsalva maneuver, ice ingestion, or stimulation of the ear canal 3, 4
• These measures work by increasing vagal efferent activity or disrupting the diaphragmatic reflex arc 5, 4

Special Anesthesia/Post-Operative Context

• If hiccups occur during anesthesia or post-extubation, administer propofol 1-2 mg/kg IV, which may be effective 1
• Apply positive pressure ventilation with 100% oxygen while avoiding unnecessary airway stimulation 1

Pharmacological Treatment for Persistent/Intractable Hiccups

Definition and Timing

• Persistent hiccups: lasting >48 hours 5
• Intractable hiccups: lasting >2 months 5
• Drug therapy becomes necessary when simple maneuvers fail and hiccups persist 3, 6

First-Line Pharmacotherapy

Chlorpromazine (FDA-approved for intractable hiccups):

• Dosage: 25-50 mg orally three to four times daily 7
• If symptoms persist for 2-3 days on oral therapy, parenteral administration is indicated 7
• This is the most widely employed agent and has FDA approval specifically for intractable hiccups 7, 3
• Important warnings: Can cause hypotension, sedation, extrapyramidal symptoms, and QT prolongation 8

Alternative Pharmacological Options

• Gabapentin has been reported effective 5
• Baclofen has emerged as a safe and often effective treatment 5, 6
• Metoclopramide (prokinetic agent) is another widely used option 3, 6

Clinical Pitfalls and Important Considerations

When to Investigate Further

• If hiccups persist despite treatment, investigate for underlying pathology including: myocardial infarction, brain tumors, stroke, gastroesophageal reflux disease, renal failure, or medication side effects 8, 5, 6
• Upper gastrointestinal investigations (endoscopy, pH monitoring) should be included systematically in chronic hiccup evaluation 6

Consequences of Untreated Persistent Hiccups

• Can lead to weight loss, depression, and sleep deprivation 8, 6
• This underscores the importance of aggressive treatment when simple measures fail 6

Medication-Induced Hiccups

• Consider drug causes including anti-parkinsonism drugs, anesthetic agents, steroids, and chemotherapy 5

Treatment Algorithm

1. Acute hiccups (<48 hours): Start with physical maneuvers (pressure at mandible/mastoid junction, HAPI technique, or vagal maneuvers) 1, 2, 4
2. If unsuccessful after multiple attempts: Consider underlying causes and begin diagnostic workup 5, 6
3. Persistent hiccups (>48 hours): Initiate chlorpromazine 25-50 mg PO three to four times daily 7
4. If oral therapy fails after 2-3 days: Switch to parenteral chlorpromazine 7
5. If chlorpromazine is contraindicated or ineffective: Trial gabapentin, baclofen, or metoclopramide 5, 6
6. Intractable cases: Consider nerve blockade, phrenic nerve pacing, or acupuncture 5, 3