What are the treatment options for chronic hiccups?

Management of Chronic Hiccups

For intractable hiccups, initiate chlorpromazine 25-50 mg three to four times daily, as this is the only FDA-approved medication for this indication and remains the first-line pharmacologic treatment. 1

Initial Assessment and Common Causes

Before initiating treatment, identify potential underlying etiologies along the hiccup reflex arc, which involves peripheral phrenic, vagal, and sympathetic pathways with central midbrain modulation 2:

• Central causes: Stroke, brain tumors, CNS injury 2, 3
• Peripheral causes: Myocardial ischemia, gastroesophageal reflux disease (GERD), gastritis, peptic ulcer disease, esophagitis, tumors, herpes infection 2, 3
• Iatrogenic causes: Anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy 2

Upper gastrointestinal investigations including endoscopy, pH monitoring, and manometry should be performed systematically, as gastric and duodenal ulcers, gastritis, and esophageal reflux are commonly observed in chronic hiccup patients 3.

Pharmacologic Treatment Algorithm

First-Line: Chlorpromazine

• Dosing: 25-50 mg orally three to four times daily 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated 1
• Chlorpromazine is the most widely employed agent and has FDA approval specifically for intractable hiccups 1, 4
• Caution: Elderly patients are more susceptible to hypotension and neuromuscular reactions; use lower doses and monitor closely 1

Second-Line Options When Chlorpromazine Fails or Is Contraindicated

Baclofen has emerged as a safe and often effective alternative treatment 3, 5:

• This GABA analog compound can be particularly valuable in patients who cannot tolerate chlorpromazine 5
• Combined medical therapy may be necessary for successful resolution 5

Metoclopramide is another widely employed agent for persistent hiccups 4, 3:

• Acts as both a prokinetic and antiemetic
• Particularly useful when GERD is suspected as the underlying cause 4

GERD-Related Hiccups: Specific Treatment Protocol

When GERD is identified as the cause, implement intensive antireflux therapy 6:

Dietary and lifestyle modifications 6:

• Eliminate foods with >45g fat per 24 hours 7
• Avoid coffee, tea, soda, chocolate, mints, citrus products (including tomatoes), and alcohol 7, 6
• No smoking 7, 6
• Limit vigorous exercise that increases intra-abdominal pressure 7, 6

Pharmacologic therapy 6:

• Initiate proton pump inhibitor (PPI) therapy 7
• If H2-antagonist was previously used, switch to PPI as proton pump inhibition may be effective when H2-antagonism has failed 7, 6
• Add prokinetic therapy (such as metoclopramide) to PPI if symptoms persist 7, 6
• Assess response within 1-3 months 7

Surgical consideration 6:

• Consider antireflux surgery only if: (1) 24-hour esophageal pH monitoring before treatment was positive, (2) patient fits clinical profile suggesting GERD as likely cause, (3) hiccups have not improved after minimum 3 months of intensive medical therapy, (4) serial pH monitoring shows medical therapy has failed to control reflux, and (5) patient reports unsatisfactory quality of life 7, 6

Non-Pharmacologic Interventions

Simple physical maneuvers that stimulate the uvula/pharynx or disrupt diaphragmatic rhythm should be attempted initially, as they often speed resolution of benign, self-limited hiccups 4:

• These measures may also terminate persistent hiccups 4

For severe, intractable cases refractory to medical therapy 4, 3:

• Physical disruption of the phrenic nerve 4
• Phrenic nerve blockade 2
• Acupuncture 2, 4
• Hypnosis 4

Critical Pitfalls to Avoid

• Do not assume hiccups are benign without investigation: Persistent hiccups (>48 hours) or intractable hiccups (>2 months) can indicate serious underlying pathology including myocardial infarction, brain tumor, renal failure, or malignancy 3
• Do not overlook GERD as a cause: Upper GI pathology is commonly observed and should be systematically investigated with endoscopy and pH monitoring 3
• Do not delay treatment: Prolonged hiccups cause significant decline in quality of life, including depression, weight loss, sleep deprivation, and patient incapacitation 3, 5, 8
• Monitor elderly patients closely: They require lower doses and are at higher risk for adverse effects from chlorpromazine 1