What are the treatment options for hiccups?

Treatment for Hiccups

For intractable hiccups, chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved first-line pharmacological treatment, though non-pharmacological vagal stimulation maneuvers should be attempted first for self-limited episodes. 1

Approach Based on Duration and Severity

Acute/Self-Limited Hiccups (< 48 hours)

Non-pharmacological interventions should be the initial approach:

• Physical maneuvers that stimulate the vagus nerve or pharynx are simple and often effective, including measures that disrupt diaphragmatic rhythm 2, 3
• Larson's maneuver (applying pressure between the posterior border of the mandible and mastoid process) can terminate hiccups effectively 2, 4
• Measures that stimulate the uvula or pharynx may speed resolution of benign, self-limited episodes 3

Persistent Hiccups (48 hours to 2 months)

If non-pharmacological measures fail after 2-3 days, pharmacological therapy is indicated:

• Chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved treatment for intractable hiccups 1
• Important caveat: Chlorpromazine can cause hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 5
• Metoclopramide is widely employed as an alternative agent 3, 6
• Baclofen has emerged as a safe and often effective treatment option 6
• Gabapentin is another pharmacological option for persistent cases 7

Intractable Hiccups (> 2 months)

A systematic diagnostic approach is essential as untreated persistent hiccups can lead to weight loss and depression: 5

• Look for central causes: stroke, brain tumors, traumatic brain injury, space-occupying lesions 5, 7, 6
• Evaluate peripheral causes along the reflex arc: myocardial ischemia, gastroesophageal reflux disease, gastric/duodenal ulcers, gastritis, esophagitis 7, 6
• Upper gastrointestinal investigations (endoscopy, pH monitoring, manometry) should be included systematically 6
• Drug-induced causes should be considered (anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapies) 7

Treatment hierarchy for intractable cases:

1. Etiological treatment when a correctable underlying cause is identified 6, 8
2. Pharmacological options if cause unknown or not correctable:
   • Chlorpromazine (FDA-approved, most established) 1, 3, 6
   • Baclofen (safe and often effective) 6
   • Gabapentin 7
   • Serotonergic agonists, prokinetics, lidocaine 7
3. Alternative interventions for refractory cases:
   • Nerve blockade 7
   • Phrenic nerve disruption 3
   • Acupuncture 7, 3
   • Intradermal injection (thiocolchicoside and lidocaine mixture at epigastric region and adjacent to sternocleidomastoid muscle) has shown success in case reports 9

Special Perioperative Considerations

For hiccups during anesthesia or post-extubation:

• Propofol 1-2 mg/kg IV may be effective 2, 4
• Ensure proper depth of anesthesia before airway manipulation 4
• In severe cases associated with laryngospasm, follow laryngospasm treatment algorithms including positive pressure ventilation with 100% oxygen 2

Dosing Specifics for Chlorpromazine

Adult dosing for intractable hiccups: 1

• 25-50 mg orally three to four times daily
• If symptoms persist for 2-3 days on oral therapy, parenteral therapy is indicated
• Elderly patients require lower dosages in the lower range due to increased susceptibility to hypotension and neuromuscular reactions

Pediatric dosing (6 months to 12 years): 1

• ¼ mg/lb body weight orally 2-3 hours before operation for presurgical hiccups
• Should generally not be used under 6 months of age except where potentially lifesaving