What are the medical management options for hiccups?

Medical Management of Hiccups

For intractable hiccups persisting beyond 2-3 days of conservative measures, chlorpromazine 25-50 mg IM/IV is the FDA-approved first-line pharmacological treatment, with baclofen as an alternative for central causes. 1, 2, 1

Initial Assessment and Conservative Measures

Physical maneuvers should be attempted first before escalating to pharmacological therapy:

• Vagal stimulation techniques include breath-holding, Valsalva maneuver, drinking cold water, or swallowing granulated sugar 3, 4
• Larson's maneuver (applying deep pressure in the "laryngospasm notch" between the posterior mandible and mastoid process while performing jaw thrust) can interrupt the hiccup reflex 5
• Suboccipital release involves gentle traction and pressure applied to the posterior neck, stretching suboccipital muscles to decompress the vagus and phrenic nerves 6

These maneuvers work by disrupting the hiccup reflex arc, which involves the phrenic nerve, vagus nerve, and respiratory center in the upper medulla 7, 4.

Pharmacological Management Algorithm

First-Line: Chlorpromazine (FDA-Approved)

Chlorpromazine is the only FDA-approved medication specifically indicated for intractable hiccups 1, 2, 1:

• Oral dosing: 25-50 mg three to four times daily 2
• Intramuscular dosing: If symptoms persist 2-3 days after oral therapy, give 25-50 mg IM 1
• Intravenous dosing: For severe cases, use slow IV infusion with patient flat in bed: 25-50 mg in 500-1000 mL saline, monitoring blood pressure closely 1
• Critical precaution: Avoid injecting undiluted chlorpromazine into vein; IV route is reserved for severe hiccups, surgery, and tetanus 1

The mechanism involves central dopaminergic blockade that interrupts the hiccup reflex arc 7, 4.

Alternative Pharmacological Options

When chlorpromazine is contraindicated or ineffective, consider these alternatives based on etiology:

For Central Causes (CNS lesions, stroke):

• Baclofen is the drug of choice for centrally-mediated hiccups 3, 8
• Acts as a GABA-B agonist to suppress the central hiccup center 7

For Peripheral Causes (gastroesophageal reflux, gastric distension):

• Metoclopramide is recommended as first-line for peripheral causes 8
• Provides both prokinetic effects and central antiemetic action 7

Additional Options:

• Gabapentin has demonstrated efficacy in persistent hiccups 7
• Propofol (1-2 mg/kg IV) can be considered during anesthesia or perioperative period 5
• Midazolam may be useful in terminal illness cases 8

Etiology-Specific Considerations

Identifying the underlying cause guides targeted therapy 3, 7:

• Gastroesophageal reflux is the most common peripheral cause; treat with proton pump inhibitors and metoclopramide 3, 8
• Central causes (stroke, tumors, CNS injury) require baclofen as first-line 8
• Metabolic causes (uremia, electrolyte imbalances) need correction of underlying abnormality 7
• Drug-induced hiccups (chemotherapy, steroids, anesthetics) may require medication adjustment 7

Interventional Approaches for Refractory Cases

When pharmacological management fails, consider invasive procedures 4, 8:

• Phrenic nerve block interrupts the efferent limb of the reflex arc 4, 8
• Vagal nerve stimulation or blockade targets the afferent pathway 4, 8
• Acupuncture has been reported effective in some cases 7, 4

Critical Pitfalls to Avoid

• Do not delay treatment beyond 48 hours (persistent hiccups) or 2 months (intractable hiccups), as prolonged episodes cause significant morbidity including weight loss, exhaustion, and aspiration risk 7
• Avoid undiluted IV chlorpromazine due to severe hypotension risk; always dilute to at least 1 mg/mL 1
• Monitor blood pressure closely during chlorpromazine administration, especially IV route 1
• In tracheotomized patients, recognize that hiccups can cause hyperventilation leading to alkalosis 3
• Do not assume benign etiology without investigating for serious underlying causes (myocardial infarction, CNS lesions, malignancy) in persistent cases 7

Special Populations

Elderly patients require lower chlorpromazine doses due to increased susceptibility to hypotension and neuromuscular reactions; start at lower range and increase gradually 1, 2

Pediatric patients (6 months to 12 years): Chlorpromazine dosing is ¼ mg/lb body weight, with maximum daily doses based on weight (40 mg/day for <50 lbs, 75 mg/day for 50-100 lbs) 1, 2