What are the treatment options for hiccups?

Treatment of Hiccups

For intractable hiccups, chlorpromazine 25-50 mg three to four times daily is the FDA-approved first-line pharmacological treatment, though baclofen has emerged as a safer alternative with comparable efficacy. 1, 2

Initial Management Approach

Non-Pharmacological Interventions (First-Line for Acute Hiccups)

• Physical maneuvers targeting the pharynx/uvula should be attempted first, including stimulation of the uvula, pharyngeal stimulation, or measures that disrupt diaphragmatic rhythm 3
• Larson's maneuver (applying deep pressure between the posterior border of the mandible and mastoid process while performing jaw thrust) can terminate hiccups 4
• These simple interventions often resolve benign, self-limited hiccup episodes without requiring medical therapy 3, 5

When to Escalate Treatment

• Persistent hiccups (>48 hours) require pharmacological intervention 6
• Intractable hiccups (>2 months) necessitate aggressive treatment and diagnostic workup 6
• Untreated persistent hiccups can lead to weight loss, depression, and sleep deprivation 7, 2

Pharmacological Treatment Algorithm

First-Line Pharmacotherapy

Chlorpromazine (FDA-approved)

• 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
• Critical warnings: Can cause hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 7
• Monitor closely for these adverse effects, particularly in elderly or debilitated patients 1

Baclofen (Emerging as Safer Alternative)

• Has emerged as a safe and often effective treatment for chronic hiccups 2
• Particularly useful when chlorpromazine is contraindicated or poorly tolerated 2, 8
• Gamma-aminobutyric acid analog that acts on the hiccup reflex arc 8

Alternative Pharmacological Options

• Metoclopramide: Prokinetic agent, classically used alongside chlorpromazine 3, 2
• Gabapentin: Effective in some cases of persistent hiccups 6
• Other agents with reported success include serotonergic agonists and lidocaine 6

Special Clinical Contexts

Perioperative/Anesthesia-Related Hiccups

• Propofol 1-2 mg/kg IV may be effective for hiccups occurring during anesthesia or post-extubation 4
• If associated with laryngospasm, apply continuous positive airway pressure with 100% oxygen while avoiding unnecessary airway stimulation 4

Diagnostic Considerations Before Treatment

Central nervous system causes to exclude:

• Brain tumors and traumatic brain injury can cause hiccups 7
• Stroke, space-occupying lesions, and CNS injury require imaging 6

Peripheral causes requiring investigation:

• Myocardial infarction, gastroesophageal reflux disease, gastric/duodenal ulcers 6, 2
• Upper gastrointestinal investigations (endoscopy, pH monitoring, manometry) should be performed systematically in chronic hiccup patients 2
• Renal failure, prostate cancer, abdominal surgery complications 2

Drug-induced hiccups:

• Anti-parkinsonism drugs, anesthetic agents, steroids, and chemotherapy can trigger hiccups 6

Refractory Cases

Advanced Interventions

• Nerve blockade: Phrenic nerve disruption for severe intractable cases 3, 6
• Acupuncture: Non-pharmacological approach with reported success 6
• Hypnosis: Alternative therapy for resistant cases 3

Treatment Monitoring

• Gradually reduce chlorpromazine dosage to the lowest effective maintenance level once symptoms are controlled 1
• Be aware that elderly patients are more susceptible to hypotension and neuromuscular reactions; observe closely and adjust dosing accordingly 1

Clinical Pitfalls to Avoid

• Do not dismiss persistent hiccups as benign without thorough evaluation—they often indicate underlying pathology requiring specific treatment 2, 5
• Do not use chlorpromazine in pediatric patients under 6 months except where potentially lifesaving 1
• Do not overlook gastrointestinal causes—gastric distention, reflux, and ulcers are commonly observed and should be investigated systematically 2
• Monitor for QT prolongation with chlorpromazine, especially with repeated dosing 7