How to Stop Hiccups
For acute, self-limited hiccups, start with simple physical maneuvers that stimulate the vagus nerve or disrupt respiratory rhythm; if hiccups persist beyond 48 hours or are intractable, pharmacologic therapy with chlorpromazine (25-50 mg three to four times daily) is indicated as the primary drug treatment. 1
Initial Management: Physical Maneuvers
For acute hiccups (lasting less than 48 hours), begin with non-pharmacologic interventions that work by increasing vagal nerve activity or disrupting diaphragmatic rhythm 2, 3:
Vagal Stimulation Techniques
- Nasopharyngeal stimulation using a swab inserted into the nostril can trigger the nasocardiac reflex and terminate hiccups within seconds 4
- Pharyngeal/uvular stimulation through various methods disrupts the hiccup reflex arc 2
- Valsalva maneuver increases efferent vagal activity 3
- Carotid sinus massage provides direct vagal stimulation 3
- Ice ingestion or cold water drinking stimulates vagal pathways 3
Respiratory Maneuvers
- HAPI technique (Hiccup relief using Active Prolonged Inspiration): Instruct the patient to inspire maximally, then continue attempting to inspire with an open glottis for 30 seconds total, followed by slow expiration - this provides immediate relief in acute cases 5
- Breath-holding measures create transient hypercapnia and disrupt the reflex 5
Important caveat: While these physical maneuvers are often effective for acute, benign hiccups, they typically fail in cases of persistent (>48 hours) or intractable (>2 months) hiccups 3.
Pharmacologic Management
First-Line Drug Therapy
Chlorpromazine is the primary pharmacologic agent for persistent or intractable hiccups 1, 2, 6:
- 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
- Critical warnings: Chlorpromazine can cause hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 7
- Monitor elderly patients closely as they are more susceptible to hypotension and neuromuscular reactions; use lower initial doses 1
Second-Line Agents
- Metoclopramide is recommended as a second-line agent based on randomized controlled trial evidence 7, 2, 6
- Gabapentin and baclofen are alternative pharmacologic options for refractory cases 6
When to Escalate Treatment
Persistent Hiccups (>48 hours)
- Transition from physical maneuvers to pharmacologic therapy 6
- Untreated persistent hiccups can lead to weight loss and depression 7
Intractable Hiccups (>2 months)
- Consider underlying pathology requiring investigation 6:
- Central causes: Stroke, brain tumors, traumatic brain injury, space-occupying lesions 7, 6
- Peripheral causes: Lesions along the reflex arc including gastroesophageal reflux disease, myocardial ischemia, tumors, herpes infection 6
- Drug-induced: Anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy 6
Refractory Cases
For hiccups unresponsive to pharmacotherapy 2, 6:
- Nerve blockade (phrenic nerve)
- Acupuncture
- Hypnosis
- Physical disruption of the phrenic nerve in extreme cases
Clinical Pitfalls
- Do not assume hiccups will self-resolve before death - this is a dangerous myth; untreated laryngospasm (a related condition) can progress to hypoxic cardiac arrest 8
- Do not delay pharmacologic treatment in persistent cases - physical maneuvers alone are usually ineffective once hiccups have lasted beyond 48 hours 3
- Screen for serious underlying pathology in any patient with persistent or intractable hiccups, as they may indicate central nervous system lesions, cardiac ischemia, or malignancy 6
- Adjust chlorpromazine dosing carefully in elderly, debilitated, or emaciated patients due to increased risk of adverse effects 1