What are the approaches for the medical management of hiccups?

Medical Management of Hiccups

For intractable hiccups, chlorpromazine 25-50 mg 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. 1

Initial Approach: Physical Maneuvers

• Vagal nerve stimulation techniques should be the first intervention for acute hiccups, including applying pressure between the posterior border of the mandible and mastoid process (Larson's maneuver), which can terminate hiccups immediately 2, 3
• Other physical maneuvers that disrupt respiratory rhythm or stimulate the pharynx/uvula are simple, safe, and often effective for self-limited episodes 4
• These non-pharmacological approaches are particularly appropriate when hiccups last less than 48 hours, as most resolve spontaneously 5

Pharmacological Management Algorithm

First-Line: Chlorpromazine (FDA-Approved)

Chlorpromazine is the only FDA-approved medication specifically indicated for intractable hiccups 1:

• 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
• This remains the most widely employed agent with formal regulatory approval 4

Alternative Pharmacological Options

When chlorpromazine is contraindicated or ineffective, consider cause-specific therapy 6:

• Baclofen: Recommended for central causes of persistent hiccups (e.g., stroke, CNS lesions) 6
• Metoclopramide: First choice for peripheral causes (e.g., gastroesophageal reflux, gastric distension) 6
• Gabapentin: Alternative option supported by evidence for persistent hiccups 7

Special Clinical Contexts

• Perioperative/anesthesia setting: Propofol 1-2 mg/kg IV can be effective when hiccups occur during anesthesia or post-extubation, with proper airway management ensured 2, 3
• Palliative care/terminal illness: Midazolam may be useful in end-of-life situations 6

Duration-Based Classification

Understanding hiccup duration guides treatment intensity 7, 5:

• Acute hiccups: <48 hours - Usually self-limited; physical maneuvers typically sufficient
• Persistent hiccups: 48 hours to 2 months - Warrant pharmacological intervention
• Intractable hiccups: >2 months - Require systematic evaluation for underlying pathology and aggressive treatment

Underlying Cause Evaluation

When hiccups persist beyond 48 hours, investigate for correctable causes 7, 5:

• Gastric overdistension is the most common identifiable cause, followed by gastroesophageal reflux 5
• Central causes include stroke, space-occupying lesions, CNS injury 7
• Peripheral causes include lesions along the reflex arc: tumors, myocardial ischemia, herpes infection, instrumentation 7
• Drug-induced hiccups from anti-parkinsonism drugs, anesthetics, steroids, chemotherapy 7

Refractory Cases

For medication-refractory persistent hiccups, interventional procedures should be considered 6:

• Vagal or phrenic nerve block or stimulation 6
• Acupuncture has been reported as successful in some cases 7, 4

Critical Pitfalls

• Do not dismiss persistent hiccups (>48 hours) as benign - they can indicate serious underlying pathology requiring investigation 5, 6
• Persistent or intractable hiccups can profoundly impact quality of life and are debilitating for patients 6
• The hiccup reflex arc involves peripheral phrenic, vagal, and sympathetic pathways with central midbrain modulation; any irritant along this pathway can trigger hiccups 7