How to control hiccups

How to Control Hiccups

For acute, self-limited hiccups, start with simple physical maneuvers targeting the vagus and phrenic nerves; for persistent hiccups lasting beyond 48 hours, initiate chlorpromazine 25-50 mg three to four times daily as first-line pharmacotherapy, while simultaneously investigating underlying causes with particular attention to gastroesophageal pathology.

Immediate Physical Maneuvers for Acute Hiccups

Simple vagal and phrenic nerve stimulation techniques should be attempted first for self-limited hiccups:

• Apply firm pressure between the posterior border of the mandible and mastoid process (similar to Larson's maneuver), which can immediately terminate hiccups 1

• The HAPI (Hiccup relief using Active Prolonged Inspiration) technique involves maximal inspiration followed by continued inspiratory effort with an open glottis for 30 seconds, then slow expiration—this method showed immediate relief in all 21 patients tested 2

• Traditional measures that stimulate the uvula/pharynx or disrupt diaphragmatic rhythm (such as breath-holding maneuvers) are simple and often effective for benign, self-limited episodes 3

Pharmacological Management for Persistent Hiccups

When hiccups persist beyond 48 hours, pharmacotherapy becomes necessary:

First-Line: Chlorpromazine

• Chlorpromazine is FDA-approved specifically for intractable hiccups at doses of 25-50 mg three to four times daily orally 4

• If symptoms persist for 2-3 days on oral therapy, parenteral administration is indicated 4

• Critical caveat: Monitor for hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 5—these adverse effects are particularly concerning in elderly or debilitated patients who require lower starting doses 4

Alternative Pharmacological Options

• Metoclopramide is widely employed as an alternative agent, particularly when gastroesophageal pathology is suspected 6, 3

• Baclofen has emerged as a safe and often effective treatment option 6, 7

• Gabapentin, serotonergic agonists, and lidocaine represent additional pharmacological approaches 7

Diagnostic Evaluation for Persistent/Intractable Hiccups

Persistent hiccups warrant investigation for underlying pathology, as they can lead to weight loss and depression if untreated 5:

Gastrointestinal Causes (Most Common)

• Upper gastrointestinal pathology—including gastric/duodenal ulcers, gastritis, GERD, and esophagitis—is the most common cause 6, 8

• First-line therapy should involve a proton pump inhibitor (PPI) with appropriate gastroenterology consultation 8

• Upper endoscopy, pH monitoring, and manometry should be included systematically in the diagnostic evaluation 6

Central Nervous System Causes

• Brain tumors and traumatic brain injury can cause hiccups 5

• Stroke, space-occupying lesions, and other CNS injuries involving the midbrain modulation centers require evaluation 7

• Brain CT scanning is indicated when central causes are suspected 6

Peripheral Causes Along the Reflex Arc

• Myocardial infarction, tumors, herpes infection, and instrumentation along the phrenic/vagal pathways can trigger hiccups 7

• Abdominal ultrasound and chest imaging help identify peripheral irritants 6

Drug-Induced Hiccups

• Anti-parkinsonism drugs, anesthetic agents, steroids, and chemotherapies are possible etiologies 7

Special Perioperative Considerations

For hiccups occurring during anesthesia or post-extubation:

• Propofol 1-2 mg/kg IV may be effective 1

• In severe cases associated with laryngospasm, follow the laryngospasm treatment algorithm including positive pressure ventilation with 100% oxygen while avoiding airway stimulation 1

Non-Pharmacological Interventions for Refractory Cases

When pharmacotherapy fails for intractable hiccups:

• Phrenic nerve blockade or pacing may be considered 7, 3

• Acupuncture has been reported as successful in some cases 7, 3

• Hypnosis represents another alternative modality 3

Clinical Algorithm Summary

1. Acute hiccups (<48 hours): Physical maneuvers (pressure at mandible/mastoid, HAPI technique)
2. Persistent hiccups (>48 hours): Initiate PPI therapy + chlorpromazine 25-50 mg TID-QID + begin diagnostic workup starting with upper GI evaluation
3. Intractable hiccups (>2 months): Expand diagnostic evaluation for central/peripheral causes + consider alternative pharmacotherapy (baclofen, gabapentin) + interventional procedures if refractory

The key pitfall is failing to recognize that persistent hiccups often signal underlying pathology requiring investigation, rather than representing a benign nuisance 6, 8.