What are the treatment options for hiccups?

Treatment for Hiccups

First-Line Approach: Simple Physical Maneuvers

For acute hiccups lasting less than 48 hours, start with physical maneuvers that stimulate the pharynx or disrupt respiratory rhythm, as these are simple, safe, and often effective. 1

• Measures targeting the uvula, pharynx, or diaphragmatic rhythm can terminate benign, self-limited hiccup episodes 1
• Most acute episodes resolve spontaneously within minutes and rarely require medical intervention 2
• Gastric distention is the most common identifiable cause of acute hiccups, followed by gastroesophageal reflux and gastritis 2

Pharmacological Treatment: When Physical Maneuvers Fail

First-Line Pharmacotherapy: Chlorpromazine

Chlorpromazine is the primary pharmacological agent for persistent hiccups (>48 hours) or intractable hiccups (>2 months), as it is FDA-approved specifically for this indication. 3

Dosing for intractable hiccups: 3

• 25-50 mg orally three to four times daily
• If symptoms persist for 2-3 days on oral therapy, switch to parenteral administration 3

Critical warnings with chlorpromazine: 4

• Can cause hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 4
• Monitor closely for these adverse effects, particularly in elderly or debilitated patients 3

Second-Line Pharmacotherapy: Metoclopramide

The American Society of Clinical Oncology recommends metoclopramide as a second-line agent when chlorpromazine fails or is contraindicated. 4

• Metoclopramide is widely employed for intractable hiccups and has been studied in randomized controlled trials 4, 1
• The National Comprehensive Cancer Network also supports metoclopramide as an alternative treatment option 4

Alternative Pharmacological Options

When first and second-line agents fail, consider: 5, 6

• Baclofen - has emerged as a safe and often effective treatment for chronic hiccups 6
• Gabapentin - acts on the reflex arc 5
• Other options include serotonergic agonists, prokinetics, and lidocaine 5

Non-Pharmacological Interventions for Refractory Cases

For severe, intractable cases unresponsive to medications: 5, 1

• Nerve blockade (phrenic nerve disruption) 5, 1
• Pacing 5
• Acupuncture 5, 1
• Hypnosis 1

Critical Clinical Considerations

When to Escalate Evaluation

Persistent hiccups beyond 48 hours warrant investigation for underlying pathology, as they can indicate serious conditions including myocardial infarction, brain tumors, renal failure, or abdominal pathology. 6, 2

• Central nervous system causes include stroke, space-occupying lesions, and traumatic brain injury 4, 5
• Peripheral causes include tumors, myocardial ischemia, herpes infection, and gastroesophageal reflux disease 5
• Upper gastrointestinal investigations (endoscopy, pH monitoring, manometry) should be included systematically, as gastric/duodenal ulcers, gastritis, and esophageal reflux are commonly observed 6

Consequences of Untreated Persistent Hiccups

Failure to treat persistent hiccups can lead to significant morbidity: 4, 6

• Weight loss 4, 6
• Depression 4, 6
• Sleep deprivation 6

Treatment Algorithm Summary

1. Acute hiccups (<48 hours): Physical maneuvers first 1, 2
2. Persistent hiccups (>48 hours): Chlorpromazine 25-50 mg PO TID-QID 3
3. If chlorpromazine fails or contraindicated: Metoclopramide 4
4. Refractory cases: Consider baclofen, gabapentin, or non-pharmacological interventions 5, 6
5. Throughout: Investigate and treat underlying etiology when identified 6, 2