What is the treatment for hiccups?

Treatment of Hiccups

For intractable hiccups, chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved first-line pharmacological treatment, while acute self-limited hiccups often respond to simple physical maneuvers targeting the vagus nerve. 1

Definition and Pathophysiology

Hiccups (singultus) result from sudden, involuntary contractions of the diaphragm and intercostal muscles, immediately followed by laryngeal closure that produces the characteristic "hic" sound. 2 The underlying mechanism involves a reflex arc with three components:

• Afferent limb: Phrenic nerve, vagus nerve, and sympathetic pathways (T6-T12) 2
• Central processing: Midbrain modulation center in the upper medulla 2, 3
• Efferent limb: Motor neurons to the diaphragm, glottis, and external intercostal muscles 3

Any irritant—physical, chemical, inflammatory, or neoplastic—affecting this reflex arc can trigger hiccups. 2

Clinical Classification

• Acute hiccups: Episodes lasting less than 48 hours (usually self-limited) 4
• Persistent hiccups: Episodes lasting 48 hours to 2 months 2, 4
• Intractable hiccups: Episodes lasting longer than 2 months 2, 4

Key Etiologies to Investigate

Gastroesophageal Causes (Most Common)

• Gastric overdistension is the most commonly identifiable cause of acute hiccups 4
• Gastroesophageal reflux disease (GERD) and gastritis 4
• For suspected GERD-related persistent hiccups, initiate high-dose proton pump inhibitor therapy with response time variable from 2 weeks to several months 5
• Consider adding prokinetic therapy (such as metoclopramide) if partial or no improvement occurs with PPI therapy alone 5
• Implement antireflux diet and lifestyle modifications concurrently 5

Central Nervous System Causes

• Brain tumors and traumatic brain injury 5
• Stroke and space-occupying lesions 2

Cardiovascular/Thoracic Causes

• Pericardial effusion compressing the phrenic nerve presents with hiccups as a local compression symptom 5
• Myocardial ischemia 2
• Obtain chest X-ray and echocardiography if pericardial or thoracic pathology is suspected 5

Other Causes

• Herpes infection, applied medical instrumentations 2
• Medications: anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy 2

Treatment Algorithm

For Acute Hiccups (< 48 hours)

Physical Maneuvers (First-line for acute episodes):

• Vagal stimulation techniques work by overstimulating the vagus nerve to interrupt the reflex arc 6:

  • Drinking cold water rapidly
  • Inducing emesis or gagging
  • Carotid sinus massage
  • Valsalva maneuver 6

• Suboccipital release technique: Apply gentle traction and pressure to the posterior neck, stretching the suboccipital muscles and fascia to manually decompress the vagus and possibly phrenic nerves 3

• Larson's maneuver adaptation: Apply pressure between the posterior border of the mandible and mastoid process, which can terminate hiccups 7

• Respiratory rhythm disruption: Breath-holding maneuvers 2

For Persistent/Intractable Hiccups (≥ 48 hours)

Pharmacological Treatment (when physical maneuvers fail):

First-line agent:

• Chlorpromazine 25-50 mg orally three to four times daily is FDA-approved specifically for intractable hiccups 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration is indicated 1
• Critical warning: Chlorpromazine can cause hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 5
• Use lower doses in elderly, emaciated, or debilitated patients who are more susceptible to hypotension and neuromuscular reactions 1

Second-line agents:

• Metoclopramide is recommended as a second-line agent, particularly useful as add-on therapy for GERD-related hiccups 5
• Gabapentin and baclofen are alternative centrally-acting agents 2, 6

Other pharmacological options:

• Serotonergic agonists, lidocaine 2

For Perioperative/Anesthesia-Related Hiccups

• Propofol 1-2 mg/kg IV may be effective for hiccups occurring during anesthesia or post-extubation 7
• Apply positive pressure ventilation with 100% oxygen and avoid unnecessary airway stimulation 7

For Refractory Cases

When medical therapy fails:

• Nerve blockade: Phrenic nerve blocking (though success is variable) 6
• Vagus nerve stimulator (VNS) placement: Emerging surgical option with partial success reported in medical refractory cases 6
• Unconventional therapies: Acupuncture, hypnosis 2, 6

Critical Clinical Pitfalls

• Do not dismiss persistent hiccups: Untreated persistent hiccups can lead to weight loss, depression, anorexia, insomnia, exhaustion, and muscle wasting 5, 6
• Persistent or intractable hiccups can be a harbinger of serious medical pathology requiring thorough investigation 4
• Escalate treatment promptly if initial physical maneuvers fail in persistent cases, as prolonged attacks can result in significant morbidity and even death 3
• Monitor for chlorpromazine side effects closely, especially in elderly patients 5, 1
• Consider 24-hour esophageal pH monitoring if empiric GERD therapy is unsuccessful 5