Treatment for Acute Hiccups
For acute hiccups, start with simple physical maneuvers that stimulate the pharynx or disrupt respiratory rhythm, and if these fail or symptoms persist beyond 2-3 days, initiate pharmacotherapy with chlorpromazine 25-50 mg three to four times daily. 1
Initial Non-Pharmacological Interventions
Physical maneuvers should be attempted first for acute hiccups, as they are simple, safe, and often effective 2:
- Stimulate the uvula or pharynx through techniques like swallowing granulated sugar, drinking cold water, or inducing a gag reflex 2
- Disrupt diaphragmatic rhythm by breath-holding, breathing into a paper bag, or performing Valsalva maneuvers 2
- Apply pressure between the posterior border of the mandible and mastoid process (similar to Larson's maneuver), which can terminate hiccups 3
Addressing Underlying Triggers
- Avoid alcohol and spicy foods to prevent gastroesophageal reflux, the most common identifiable cause of acute hiccups 4, 5, 6
- Treat gastric overdistension if present, as this is the most frequently identified trigger 6
Pharmacological Treatment
When physical maneuvers fail or symptoms persist for 2-3 days, pharmacotherapy becomes necessary 1, 2:
First-Line Pharmacotherapy: Chlorpromazine
Chlorpromazine is the drug of choice for intractable hiccups and is FDA-approved for this indication 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 is one of the most widely employed agents with established efficacy 2, 7
Alternative Pharmacological Options
Other medications that may be effective include 2, 7:
- Metoclopramide (prokinetic agent) 2, 7
- Baclofen (considered treatment of choice in some protocols for persistent hiccups) 5, 7
- Gabapentin 7
Special Circumstances: Severe Cases with Respiratory Compromise
For severe hiccups causing respiratory distress 4, 3:
- Apply continuous positive airway pressure with 100% oxygen 4
- Consider Larson's maneuver (pressure at the "laryngospasm notch") 4
- Administer propofol 1-2 mg/kg IV for persistent cases with oxygen desaturation 4, 3
- Monitor for respiratory complications including potential laryngospasm and post-obstructive pulmonary edema 4
Important Caveats
- Most acute hiccups resolve spontaneously within minutes and rarely require medical intervention if lasting less than 48 hours 6
- Persistent hiccups (>48 hours) or intractable hiccups (>2 months) warrant investigation for underlying pathology including gastrointestinal, neurological, cardiovascular, or infectious causes 6, 7
- The evidence base for hiccup treatments relies heavily on case reports and anecdotal experience rather than controlled trials, though chlorpromazine has FDA approval and the strongest supporting evidence 2, 6