What can be used to treat hiccups?

Treatment of Hiccups

For intractable hiccups, chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved first-line treatment, with metoclopramide and baclofen serving as effective alternatives when chlorpromazine is contraindicated or ineffective. 1

First-Line Pharmacological Treatment

Chlorpromazine remains the only FDA-approved medication specifically indicated for intractable hiccups. 1

• Dosing: 25-50 mg orally three to four times daily for intractable hiccups 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration should be considered 1
• Critical warnings: Monitor for hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 2
• Chlorpromazine can cause significant cardiovascular and neurological side effects that require close monitoring 2

Second-Line Pharmacological Options

When chlorpromazine is contraindicated or ineffective, alternative agents should be considered:

Metoclopramide is recommended as a second-line agent by the American Society of Clinical Oncology based on randomized controlled trial evidence 2

• Particularly useful when gastroesophageal reflux disease (GERD) is suspected as the underlying cause 2
• Can be combined with proton pump inhibitor (PPI) therapy for GERD-related hiccups 2

Baclofen has emerged as a safe and effective treatment option for chronic hiccups 3

• Gabapentin may be added to baclofen as a reasonable combination therapy 4
• This combination appears particularly promising in palliative care populations 4

Treatment Based on Underlying Etiology

For GERD-suspected hiccups, the American Thoracic Society recommends initiating high-dose PPI therapy, with response time variable from 2 weeks to several months 2

• Implement antireflux diet and lifestyle modifications concurrently 2
• Add prokinetic therapy (such as metoclopramide) if partial or no improvement occurs 2
• Consider 24-hour esophageal pH monitoring if empiric therapy is unsuccessful 2

Diagnostic Considerations Before Treatment

Persistent hiccups warrant investigation for serious underlying pathology:

• Brain tumors and traumatic brain injury are central nervous system causes 2
• Pericardial effusion compressing the phrenic nerve can manifest as hiccups 2
• Imaging including chest X-ray and echocardiography is recommended if pericardial or thoracic pathology is suspected 2
• Upper gastrointestinal investigations (endoscopy, pH monitoring) should be included systematically, as gastric/duodenal ulcers, gastritis, and esophageal reflux are commonly observed 3

Duration-Based Classification and Treatment Approach

Acute hiccups (< 48 hours):

• Usually self-limited and rarely require medical intervention 5
• Simple physical maneuvers that stimulate the uvula/pharynx or disrupt diaphragmatic rhythm may help 6

Persistent hiccups (> 48 hours):

• Warrant pharmacological intervention 5
• Begin with chlorpromazine or metoclopramide 6, 3

Intractable hiccups (> 2 months):

• Require aggressive pharmacological management 4
• Can cause depression, weight loss, and sleep deprivation if untreated 2, 3
• Consider baclofen with or without gabapentin if first-line agents fail 4

Critical Pitfalls to Avoid

• Do not dismiss persistent hiccups as benign - they can indicate serious pathology including myocardial infarction, brain tumors, renal failure, or malignancy 3
• Do not delay treatment of intractable hiccups - untreated cases lead to significant morbidity including weight loss and depression 2
• Monitor closely for chlorpromazine side effects - hypotension and QT prolongation can be life-threatening 2

Pediatric Considerations

For children 6 months to 12 years with severe hiccups:

• Chlorpromazine dosing: ¼ mg/lb body weight orally every 4-6 hours as needed 1
• Should generally not be used in children under 6 months except when potentially lifesaving 1