What are the treatment options for hiccups?

Treatment for Hiccups

Immediate Management Approach

For intractable hiccups (lasting >48 hours), chlorpromazine is the FDA-approved first-line pharmacological treatment, dosed at 25-50 mg orally three to four times daily, with parenteral administration reserved for cases unresponsive to oral therapy after 2-3 days. 1, 2

Treatment Algorithm by Duration and Severity

Acute Hiccups (<48 hours)

Non-pharmacological interventions should be attempted first:

• Physical maneuvers that stimulate the pharynx/uvula or disrupt respiratory rhythm are simple first-line approaches 3
• These include breath-holding techniques, pharyngeal stimulation, or measures that alter diaphragmatic rhythm 3
• Most acute episodes are self-limited and resolve spontaneously or with these simple interventions 4

Persistent Hiccups (48 hours to 1 month)

Monitor closely for complications:

• Patients approaching 48 hours require monitoring for respiratory compromise, particularly those with pre-existing respiratory conditions, as severe cases can progress to laryngospasm and post-obstructive pulmonary edema 5
• Untreated persistent hiccups can lead to weight loss and depression 6

Pharmacological treatment becomes necessary:

• Chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved treatment for intractable hiccups 1, 2
• If symptoms persist for 2-3 days on oral therapy, parenteral administration is indicated 1
• Intramuscular dosing: 25-50 mg IM, which can be repeated if no hypotension occurs 2
• Intravenous route (reserved for severe cases): 25-50 mg diluted in 500-1000 mL saline as slow IV infusion with patient supine and close blood pressure monitoring 2

Intractable Hiccups (>1 month)

Escalate to parenteral chlorpromazine if oral therapy fails:

• IM administration: 25-50 mg, given 3-4 times daily 2
• IV infusion for severe cases: 25-50 mg in 500-1000 mL saline, administered slowly with continuous blood pressure monitoring and patient flat in bed 2

Alternative pharmacological agents (when chlorpromazine is contraindicated or ineffective):

• Metoclopramide and baclofen have been reported as alternatives, though chlorpromazine remains the only FDA-approved agent 3, 4
• Gabapentin, serotonergic agonists, and lidocaine are additional options reported in the literature 7

Critical Safety Considerations

Chlorpromazine carries significant risks that require monitoring:

• Hypotension is a major concern—patients should remain supine for at least 30 minutes after parenteral administration 2
• Sedation, extrapyramidal symptoms, and QT interval prolongation are additional adverse effects 6
• Elderly patients are more susceptible to hypotension and neuromuscular reactions and require lower initial doses with gradual titration 1, 2
• Dosage should be increased more gradually in debilitated or emaciated patients 1, 2

Avoid subcutaneous injection and never inject undiluted chlorpromazine into a vein 2

Diagnostic Workup for Persistent/Intractable Cases

Identify underlying etiology as treatment should address the root cause when possible:

• Central nervous system causes include brain tumors, traumatic brain injury, and stroke 6, 7
• Peripheral causes include lesions along the reflex arc: myocardial infarction, gastroesophageal reflux disease, tumors, and herpes infection 7
• Upper gastrointestinal investigations (endoscopy, pH monitoring) should be included systematically as gastric/duodenal ulcers, gastritis, and esophageal reflux are commonly observed 4
• Drug-induced hiccups from anti-parkinsonism drugs, anesthetic agents, steroids, and chemotherapies should be considered 7

Evidence Quality Note

The evidence base for hiccup treatment is limited—a 2013 Cochrane review found insufficient high-quality evidence to guide treatment, with no RCTs of pharmacological interventions meeting inclusion criteria 8. Despite this, chlorpromazine remains the FDA-approved standard based on clinical experience and is widely employed for intractable hiccups 2, 3, 4.