What are the treatment options for hiccups?

Treatment of Hiccups

For intractable hiccups, chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved first-line pharmacological treatment, while simple physical maneuvers should be attempted first for acute, benign hiccups.

Acute/Self-Limited Hiccups

Non-Pharmacological Maneuvers (First-Line)

• Apply firm pressure between the posterior border of the mandible and mastoid process (similar to Larson's maneuver), which can terminate hiccups immediately 1
• Stimulate the uvula or pharynx through various physical maneuvers to disrupt the reflex arc 2
• Employ techniques that disrupt diaphragmatic rhythm, such as breath-holding or breathing pattern changes 2
• These simple measures are often sufficient to terminate benign, self-limited hiccup episodes 2

Persistent Hiccups (>48 hours) and Intractable Hiccups (>2 months)

Pharmacological Treatment

Chlorpromazine (First-Line)

• FDA-approved specifically for intractable hiccups at 25-50 mg orally three to four times daily 3
• If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated 3
• Chlorpromazine is one of the most widely employed agents and has established efficacy 2, 4
• Monitor elderly patients closely as they are more susceptible to hypotension and neuromuscular reactions; use lower dosages in this population 3

Alternative Pharmacological Agents

• Baclofen has emerged as a safe and often effective treatment for chronic hiccups, particularly when chlorpromazine fails or is contraindicated 5, 6
• Metoclopramide is another widely used agent, especially when gastrointestinal causes are suspected 2, 4
• Gabapentin can be considered as an alternative option 4

Special Clinical Contexts

Perioperative/Anesthesia Setting

• For hiccups during anesthesia or post-extubation, propofol 1-2 mg/kg IV may be effective 1
• In severe cases associated with laryngospasm, follow the laryngospasm treatment algorithm including positive pressure ventilation with 100% oxygen 1

Refractory Cases

• Phrenic nerve blockade or reversible thoracoscopic nerve clipping can be considered when medical therapy fails 4, 7
• Acupuncture and hypnosis have been reported as alternative approaches 2, 4

Diagnostic Considerations

Identify Underlying Etiology

• Gastroesophageal reflux disease and gastritis are the most common causes of chronic hiccups 5, 6
• Upper gastrointestinal investigations (endoscopy, pH monitoring) should be performed systematically in persistent cases 6
• Central causes include stroke, space-occupying lesions, and CNS injury 4
• Peripheral causes include myocardial ischemia, tumors along the phrenic/vagal nerve pathways, and herpes infection 4
• Drug-induced hiccups can result from anti-parkinsonism drugs, anesthetic agents, steroids, and chemotherapy 4

Treatment Algorithm Priority

1. Acute hiccups (<48 hours): Physical maneuvers first 1, 2
2. Persistent hiccups (>48 hours): Initiate chlorpromazine 25-50 mg TID-QID 3
3. If chlorpromazine fails or contraindicated: Switch to baclofen 5, 6
4. Refractory to medical therapy: Consider nerve blockade or surgical intervention 4, 7

Important Caveats

• Most hiccup "cures" are based on anecdotal experience rather than controlled clinical studies, making evidence-based recommendations challenging 2
• Chlorpromazine remains the only FDA-approved medication specifically indicated for intractable hiccups 3
• Etiological treatment should be pursued when an underlying cause is identified, as this may resolve hiccups without symptomatic therapy 6
• Prolonged hiccups can cause significant morbidity including depression, weight loss, and sleep deprivation, warranting aggressive treatment 6