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-choice 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
- Serotonergic agonists 6
- Lidocaine 6
- Midazolam may be particularly useful in terminal illness settings 5
Perioperative/Anesthesia Setting
- Propofol (1-2 mg/kg IV) can be considered for hiccups occurring during anesthesia or in the perioperative period 1
- Ensure proper depth of anesthesia before any airway manipulation 1
Refractory Cases
When medications fail, interventional procedures should be considered 5:
- Vagal nerve block or stimulation
- Phrenic nerve block or stimulation
- Acupuncture 6
Critical Clinical Pearls
Duration-based classification guides management 6, 3:
- Acute: <48 hours (usually self-limited, physical maneuvers sufficient)
- Persistent: >48 hours (requires pharmacological intervention)
- Intractable: >2 months (may require interventional procedures)
Common pitfall: Persistent or intractable hiccups can indicate serious underlying pathology 3. The most common identifiable causes are gastric overdistension, gastroesophageal reflux, and gastritis 3, but neurological, cardiovascular, pulmonary, infectious, and neoplastic etiologies must be considered 6.
Important caveat: Most treatment recommendations are based on case reports and anecdotal evidence rather than controlled trials 2, 3. The systematic approach outlined above represents the best available evidence, with chlorpromazine having the strongest regulatory approval for this indication 4.