What is the best approach to treat hiccups in a 20-year-old?

Treatment of Hiccups in a 20-Year-Old

For acute hiccups in a 20-year-old, start with simple physical maneuvers, and if these fail or hiccups persist beyond 48 hours, initiate pharmacological therapy with chlorpromazine 25-50 mg three to four times daily as first-line treatment, as it is the only FDA-approved medication for intractable hiccups. 1

Initial Approach: Physical Maneuvers

For acute hiccups (lasting less than 48 hours), begin with non-pharmacological interventions that are simple, safe, and often effective 2, 3:

• Apply firm pressure between the posterior border of the mandible and the mastoid process (similar to Larson's maneuver), which can terminate hiccups 4
• Stimulate the uvula or pharynx through maneuvers that disrupt the hiccup reflex arc 3
• Disrupt diaphragmatic rhythm through breath-holding techniques or other respiratory maneuvers 3

These physical interventions work by interrupting the reflex arc involving the phrenic nerve, vagus nerve, and central midbrain pathways 2.

When to Escalate to Pharmacological Treatment

Persistent hiccups (lasting 48 hours to 2 months) or intractable hiccups (lasting beyond 2 months) require pharmacological intervention 2, 5. Most acute hiccups resolve within minutes and rarely require medical intervention 6.

Pharmacological Treatment Algorithm

First-Line: Chlorpromazine

• Dosage: 25-50 mg orally three to four times daily 1
• This is the only FDA-approved medication specifically indicated for intractable hiccups 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated 1
• Caution: Monitor for hypotension and neuromuscular reactions, particularly in elderly patients (though less relevant for a 20-year-old) 1

Alternative First-Line Options (Based on Systematic Review)

While chlorpromazine has FDA approval, a 2015 systematic review suggests baclofen and gabapentin may be considered as first-line therapy due to better long-term safety profiles, though they lack the regulatory approval that chlorpromazine has 5:

• Baclofen: Supported by small randomized placebo-controlled trials 5
• Gabapentin: Supported by observational data with fewer side effects during long-term therapy 5

Second-Line: Metoclopramide

• Supported by small randomized placebo-controlled trials 5
• One of the most widely employed agents for persistent hiccups 3
• Works as a prokinetic agent, particularly useful if gastroesophageal reflux is suspected 5

Important Clinical Considerations

Identify and Treat Underlying Causes

Management is most effective when directed at the underlying condition 5:

• Gastric overdistension is the most common identifiable cause in acute hiccups 6
• Gastroesophageal reflux disease (GERD) and gastritis are frequent culprits 2, 6
• Consider an empirical trial of anti-reflux therapy if GERD is suspected 5

Red Flags Requiring Further Investigation

Persistent or intractable hiccups can indicate serious pathology 6:

• Central nervous system lesions (stroke, tumors, injury) 2
• Peripheral nerve irritation along the phrenic or vagus nerve 2
• Cardiovascular causes (myocardial ischemia) 2
• Drug-induced (anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy) 2

Special Circumstances

• If hiccups occur during or post-anesthesia: Propofol 1-2 mg/kg IV may be effective 4
• If associated with laryngospasm: Follow laryngospasm treatment algorithm including positive pressure ventilation with 100% oxygen 4

Evidence Quality and Limitations

Critical caveat: The systematic review revealed no adequately powered, well-designed trials for hiccup treatment 5. Most recommendations are based on case reports and anecdotal evidence rather than controlled clinical studies 3, 6. The evidence base consists of only 341 patients across 15 published studies 5.

Despite limited high-quality data, chlorpromazine remains the standard due to FDA approval and decades of clinical use 1, 5, though baclofen and gabapentin offer potentially safer alternatives for long-term management 5.