What are the treatment options for hiccups (synchronous diaphragmatic contractions)?

Hiccup Treatment

For acute, self-limited hiccups, begin with simple physical maneuvers (breath-holding, Valsalva), but for persistent hiccups (>48 hours), initiate pharmacological therapy with chlorpromazine 25-50 mg orally three to four times daily as first-line treatment, as this is the only FDA-approved medication for intractable hiccups. 1

Initial Assessment and Classification

Hiccups must be classified by duration to guide treatment intensity:

• Acute hiccups: Self-limited episodes lasting minutes to hours
• Persistent hiccups: Episodes lasting >48 hours 2
• Intractable hiccups: Episodes lasting >2 months 2

The underlying mechanism involves a reflex arc with peripheral phrenic, vagal, and sympathetic pathways modulated centrally in the midbrain 2. Any irritant—physical, chemical, inflammatory, or neoplastic—along this arc can trigger hiccups 2.

Treatment Algorithm

Step 1: Physical Maneuvers (First-Line for Acute Hiccups)

Simple non-pharmacological interventions targeting the reflex arc components:

• Breath-holding techniques 3
• Valsalva maneuver 2
• Suboccipital release: Apply gentle traction and pressure to the posterior neck, stretching suboccipital muscles and fascia to decompress the vagus and phrenic nerves 3

Step 2: Identify and Treat Underlying Cause

For gastroesophageal reflux disease (GERD) as suspected cause:

• Initiate high-dose proton pump inhibitor (PPI) therapy 4
• Implement antireflux diet and lifestyle modifications concurrently 4
• Add prokinetic therapy (metoclopramide) if partial or no improvement occurs 4
• Response time is variable, ranging from 2 weeks to several months 4
• Consider 24-hour esophageal pH monitoring if empiric therapy unsuccessful 4

Central nervous system causes to evaluate:

• Brain tumors 4
• Traumatic brain injury 4
• Stroke, space-occupying lesions 2

Peripheral causes to consider:

• Myocardial ischemia, herpes infection, gastric distention 2, 5
• Diaphragmatic eventration (rare but documented cause) 6

Step 3: Pharmacological Treatment for Persistent/Intractable Hiccups

First-line pharmacological agent:

• Chlorpromazine 25-50 mg orally three to four times daily 1
• If symptoms persist for 2-3 days, administer 25-50 mg intramuscularly 7
• For severe cases requiring IV route: dilute 25-50 mg in 500-1000 mL saline and infuse slowly with patient supine, monitoring blood pressure closely 7

Critical warnings for chlorpromazine:

• Can cause hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 4
• Monitor blood pressure during administration 7
• Use lower doses in elderly, emaciated, or debilitated patients 1, 7

Second-line pharmacological agents:

• Metoclopramide: Recommended as second-line agent by the American Society of Clinical Oncology 4
• Particularly effective for peripheral causes of hiccups 8
• Baclofen: Drug of choice for central causes of persistent hiccups 8
• Successfully used in diaphragmatic eventration case 6

Alternative pharmacological options:

• Gabapentin 2
• Serotonergic agonists 2
• Lidocaine 2
• Midazolam may be useful in terminal illness 8

Step 4: Interventional Procedures (Refractory Cases)

For medication-refractory hiccups:

• Phrenic nerve blockade 2, 5
• Vagal nerve block or stimulation 8
• Phrenic nerve pacing 2
• Acupuncture 2

Critical warning for phrenic nerve block:

• Risk of pneumothorax, particularly in patients with thin necks 5
• Requires nerve stimulator guidance for localization 5
• Tube thoracostomy may be necessary if pneumothorax occurs 5

Clinical Pitfalls to Avoid

Do not dismiss persistent hiccups as benign: Untreated persistent hiccups can lead to weight loss and depression 4, and prolonged attacks can result in significant morbidity and even death 3.

Do not delay pharmacological treatment: If simple physical maneuvers fail and hiccups persist beyond 48 hours, initiate chlorpromazine promptly rather than continuing ineffective conservative measures 1.

Do not overlook serious underlying pathology: Intractable hiccups often indicate serious underlying disease ranging from neoplasms to structural abnormalities 6. A systematic evaluation for central and peripheral causes is mandatory 2.

Recognize that voice therapy may be beneficial: In cases associated with laryngospasm, prescribe voice therapy to establish rescue breathing techniques 6.