What are the treatment options for hiccups?

Treatment of Hiccups

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

Initial Approach: Physical Maneuvers

• Begin with vagal nerve stimulation techniques such as Larson's maneuver, which can effectively terminate hiccup episodes through neurophysiological disruption of the reflex arc 1
• Other physical maneuvers that disrupt the diaphragmatic rhythm or stimulate the uvula/pharynx are simple, safe, and often effective for self-limited hiccups 2
• These non-pharmacological interventions should be the first-line approach for acute hiccups lasting less than 48 hours 3

Pharmacological Treatment Algorithm

For Intractable Hiccups (>48 hours)

Chlorpromazine remains the only FDA-approved medication specifically indicated for intractable hiccups 4:

• Dosing: 25-50 mg orally three to four times daily 4
• If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated 4
• Chlorpromazine is one of the most widely employed agents with established efficacy 2

Alternative Pharmacological Options

The choice between central versus peripheral acting agents depends on the suspected etiology 5:

For central causes (stroke, CNS lesions):

• Baclofen is the drug of choice for centrally-mediated persistent hiccups 5
• Gabapentin has demonstrated efficacy in the reflex arc modulation 6

For peripheral causes (gastroesophageal reflux, gastric distension):

• Metoclopramide is recommended as first-line for peripherally-mediated hiccups 5
• This addresses the most common identifiable cause: gastric overdistension and reflux 3

Other pharmacological agents with reported efficacy include:

• Baclofen for general use in persistent hiccups 6
• Midazolam may be particularly useful in terminal illness settings 5
• Serotonergic agonists and lidocaine have shown benefit 6

Special Considerations

Perioperative/Anesthesia Setting

• Propofol (1-2 mg/kg IV) can be considered for hiccups during anesthesia or the perioperative period, ensuring proper depth of anesthesia before airway manipulation 1

Refractory Cases

• Interventional procedures such as vagal or phrenic nerve block or stimulation should be considered when medications fail 5
• Physical disruption of the phrenic nerve, hypnosis, and acupuncture represent additional options for severe, intractable cases 2, 6

Critical Clinical Pitfalls

• Do not dismiss persistent hiccups (>48 hours) as benign - they can indicate serious underlying pathology including CNS lesions, myocardial ischemia, or malignancy 6, 3
• Identify the underlying cause when possible - gastroesophageal reflux, gastritis, and gastric overdistension are the most common treatable etiologies 3
• Consider medication-induced hiccups - anti-parkinsonism drugs, anesthetic agents, steroids, and chemotherapy can all trigger hiccups 6
• The hiccup reflex arc involves peripheral phrenic, vagal, and sympathetic pathways with central midbrain modulation - lesions anywhere along this pathway can cause persistent hiccups 6

Evidence Quality Note

Most hiccup treatment recommendations are based on case reports and anecdotal evidence rather than controlled trials 2, 3. However, chlorpromazine's FDA approval for intractable hiccups provides the strongest regulatory support for pharmacological intervention 4. The lack of formal treatment guidelines necessitates a systematic, stepwise approach starting with the safest interventions and escalating based on response 3.