What is the treatment for acute hiccups?

Treatment for Acute Hiccups

For acute hiccups lasting less than 48 hours, start with simple physical maneuvers and address underlying causes; chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved pharmacologic treatment if symptoms persist for 2-3 days. 1, 2

Initial Management Approach

Physical Maneuvers (First-Line)

• Stimulate the pharynx or uvula through maneuvers that disrupt the diaphragmatic rhythm, as these are simple and often effective for self-limited hiccups 3
• Hold breath or perform breathing exercises to interrupt the reflex arc 4
• These measures work by disrupting the hiccup reflex arc involving peripheral phrenic, vagal, and sympathetic pathways 4

Address Common Underlying Causes

• Gastric overdistension is the most common identifiable cause, followed by gastroesophageal reflux and gastritis 5
• Avoid alcohol and spicy foods to prevent gastroesophageal reflux 6
• Most acute hiccup episodes resolve spontaneously within minutes and rarely require medical intervention 5

Pharmacologic Treatment (If Physical Maneuvers Fail)

Chlorpromazine (FDA-Approved, First-Line Pharmacotherapy)

If symptoms persist for 2-3 days after physical maneuvers, initiate chlorpromazine 25-50 mg orally three to four times daily 1, 2

• This is the only FDA-approved medication specifically indicated for intractable hiccups 2
• Chlorpromazine is one of the most widely employed agents for persistent hiccups 3
• Important safety considerations: Can cause hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 7
• Use lower doses in elderly, debilitated, or emaciated patients due to increased susceptibility to hypotension and neuromuscular reactions 1

Alternative Pharmacologic Options

If chlorpromazine is contraindicated or ineffective:

• Metoclopramide is another widely used agent for hiccups 3
• Baclofen appears promising for persistent cases 8
• Gabapentin may be used as add-on therapy to baclofen 8

Severe Cases with Respiratory Compromise

Emergency Interventions

For severe hiccups causing respiratory distress (rare in acute cases):

1. Apply continuous positive airway pressure with 100% oxygen while ensuring airway patency 6
2. Consider Larson's maneuver: Apply deep pressure at the "laryngospasm notch" between the posterior mandible and mastoid process while performing jaw thrust 6
3. Propofol 1-2 mg/kg IV may be needed for persistent cases with oxygen desaturation 6

Monitor for Complications

• Watch for signs of respiratory distress or laryngospasm 6
• Be aware that severe, unrelieved cases can potentially lead to post-obstructive pulmonary edema 6

Clinical Pitfalls and Caveats

Duration Classification Matters

• Acute hiccups: Less than 48 hours (usually self-limited) 4, 5
• Persistent hiccups: Longer than 48 hours (may require pharmacotherapy) 4, 5
• Intractable hiccups: More than 2 months (requires thorough evaluation for underlying pathology) 4, 5

When to Escalate Care

• If hiccups persist beyond 48 hours despite initial treatment, consider persistent hiccups and evaluate for underlying pathology 5
• Persistent or intractable hiccups can indicate serious medical conditions including CNS lesions (stroke, tumors, traumatic brain injury), myocardial ischemia, or malignancy 7, 4
• Untreated persistent hiccups can lead to weight loss and depression 7

Medication-Induced Hiccups

Be aware that various drugs can cause hiccups, including anti-parkinsonism drugs, anesthetic agents, steroids, and chemotherapy 4