Treatment of Acute Hiccups
For acute hiccups, start with simple physical maneuvers and address underlying triggers like gastric distention or gastroesophageal reflux; reserve pharmacotherapy with chlorpromazine 25-50 mg three to four times daily for persistent cases lasting beyond 48 hours, and consider respiratory support measures for severe cases with oxygen desaturation.
Initial Management Approach
Non-Pharmacological Interventions
- Physical maneuvers that stimulate the pharynx or disrupt diaphragmatic rhythm should be attempted first, as they are simple, safe, and often effective for self-limited acute hiccups 1
- Measures that stimulate the uvula or pharynx can help terminate benign hiccup episodes 1
- For severe cases with respiratory compromise, Larson's maneuver (applying pressure at the "laryngospasm notch") may be employed 2
- Pulling the tongue forward can stimulate the vagus nerve or disrupt diaphragmatic rhythm 3
Addressing Underlying Triggers
- Avoid alcohol and spicy foods to prevent gastroesophageal reflux, which is a common precipitant of acute hiccups 2
- Gastric overdistension is the most commonly identifiable cause, followed by gastroesophageal reflux and gastritis 4
- Most acute hiccup bouts lasting less than 48 hours resolve spontaneously and rarely require medical intervention 4
Pharmacological Treatment
First-Line Medication
- Chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved first-line pharmacotherapy for intractable hiccups 5
- If symptoms persist for 2-3 days with oral therapy, parenteral administration should be considered 5
- Monitor for side effects including sedation, hypotension, and extrapyramidal symptoms 3
Alternative Pharmacological Options
- Metoclopramide is widely employed as an alternative agent, particularly when gastric motility issues are suspected 1, 6
- Baclofen has emerged as a safe and often effective treatment option 6
- Gabapentin and serotonergic agonists may also be considered 7
Management of Severe Cases with Respiratory Compromise
Respiratory Support
- Apply continuous positive airway pressure with 100% oxygen for severe cases with respiratory compromise 2
- Propofol 1-2 mg/kg IV may be necessary for persistent cases with oxygen desaturation 2
- Monitor closely for respiratory complications including potential laryngospasm and post-obstructive pulmonary edema 2
Clinical Pitfalls and Caveats
- Acute hiccups lasting less than 48 hours are usually benign and self-limited; aggressive intervention is typically unnecessary 4
- Persistent hiccups (>48 hours) or intractable hiccups (>2 months) warrant investigation for underlying pathology including myocardial infarction, brain tumors, renal failure, or gastrointestinal disorders 7, 6
- In elderly or debilitated patients, start with lower chlorpromazine doses and increase gradually, as they are more susceptible to hypotension and neuromuscular reactions 5
- For cancer patients on opioids, consider opioid rotation as some opioids may trigger hiccups 3