What are the management options for hiccups?

Management of Hiccups

For intractable hiccups, chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved first-line pharmacological treatment, while simple physical maneuvers should be attempted first for acute episodes. 1

Initial Assessment and Classification

Hiccups must be categorized by duration to guide management:

• Acute hiccups: Self-limited episodes lasting less than 48 hours 2, 3
• Persistent hiccups: Episodes lasting 48 hours to 2 months 2
• Intractable hiccups: Episodes exceeding 2 months 2

Non-Pharmacological Management

First-Line Physical Maneuvers

For acute hiccups, attempt these simple interventions before considering medications:

• Larson's maneuver: Apply pressure with the middle finger of each hand in the "laryngospasm notch" between the posterior border of the mandible and mastoid process while displacing the mandible forward in a jaw thrust 4, 5
• Pharyngeal stimulation: Stimulate the uvula or pharynx to disrupt the reflex arc 6
• Respiratory maneuvers: Breath-holding or other techniques that disrupt diaphragmatic rhythm 6, 2

Special Considerations for Perioperative Hiccups

If hiccups occur during anesthesia or in the post-extubation period:

• Apply continuous positive airway pressure with 100% oxygen using a reservoir bag and facemask while ensuring upper airway patency 5
• Avoid unnecessary upper airway stimulation 5
• Propofol 1-2 mg/kg IV may be effective for persistent cases with oxygen desaturation 4, 5
• Monitor closely for respiratory complications including potential progression to laryngospasm and post-obstructive pulmonary edema 5

Pharmacological Management

FDA-Approved First-Line Treatment: Chlorpromazine

For intractable hiccups that persist for 2-3 days despite physical maneuvers:

• Oral dosing: 25-50 mg three to four times daily 1
• If symptoms persist after 2-3 days of oral therapy, parenteral administration is indicated 1
• Intramuscular dosing: 25-50 mg IM; if symptoms persist, use slow IV infusion with patient flat in bed: 25-50 mg in 500-1000 mL saline 7
• Critical safety measure: Follow blood pressure closely due to hypotension risk 7
• Chlorpromazine is one of the most widely employed agents and has established efficacy 6, 3

Alternative Pharmacological Options

When chlorpromazine is contraindicated or ineffective:

• Metoclopramide: Particularly effective for peripheral causes of hiccups (gastric distention, gastroesophageal reflux) 6, 3, 8
• Baclofen: Emerging as a safe and effective treatment, particularly for central causes of persistent hiccups 3, 8
• Gabapentin: Alternative option for refractory cases 2

Treatment Algorithm by Etiology

For peripheral causes (gastric distention, gastroesophageal reflux, esophagitis):

• First choice: Metoclopramide 8
• Consider upper gastrointestinal investigations (endoscopy, pH monitoring) as these conditions are commonly observed in chronic hiccup patients 3

For central causes (stroke, brain tumors, CNS lesions):

• First choice: Baclofen 8

For palliative care patients with terminal illness:

• Consider midazolam as a useful option 8

Common Pitfalls and Caveats

• Do not delay parenteral chlorpromazine if oral therapy fails after 2-3 days, as prolonged hiccups can cause depression, weight loss, and sleep deprivation 3
• Avoid subcutaneous injection of chlorpromazine; inject slowly, deep into upper outer quadrant of buttock 7
• Never inject undiluted chlorpromazine into a vein; IV route is only for severe hiccups, surgery, and tetanus 7
• Monitor for hypotension with chlorpromazine; keep patients lying down for at least 30 minutes after injection 7
• In elderly patients, use lower dosages as they are more susceptible to hypotension and neuromuscular reactions 1, 7

Refractory Cases

For patients who fail pharmacological management:

• Interventional procedures: Consider vagal or phrenic nerve block or stimulation 2, 8
• Physical disruption of the phrenic nerve in severe cases 6
• Acupuncture has been reported as successful in some cases 2
• Hypnosis may be considered 6

Underlying Etiology Investigation

While initiating symptomatic treatment, investigate potential causes as etiological treatment may be available:

• Common peripheral causes include myocardial infarction, gastric/duodenal ulcers, gastritis, esophageal reflux, abdominal surgery, and prostate cancer 3
• Central causes include stroke, brain tumors, and CNS injury 2
• Drug-induced hiccups can result from anti-parkinsonism drugs, anesthetic agents, steroids, and chemotherapies 2