What are the treatment options for hiccups?

Treatment for Hiccups

First-Line Pharmacological Treatment

For intractable hiccups, chlorpromazine 25-50 mg three to four times daily is the FDA-approved treatment and should be initiated if simple measures fail, with dose escalation as needed up to several hundred milligrams daily. 1

FDA-Approved Dosing for Intractable Hiccups

• Start with chlorpromazine 25-50 mg orally three to four times daily 1
• If symptoms persist for 2-3 days on oral therapy, switch to parenteral administration 1
• Dosage can be increased gradually based on response, though most patients respond to standard doses 1
• Critical warning: Chlorpromazine causes hypotension, sedation, extrapyramidal symptoms, and QT prolongation 2

Cause-Specific Treatment Approach

When GERD is Suspected

• Initiate high-dose proton pump inhibitor (PPI) therapy immediately, as recommended by the American Thoracic Society 2
• Response time is variable, ranging from 2 weeks to several months 2
• Add prokinetic therapy (such as metoclopramide) if partial or no improvement occurs 2
• Implement antireflux diet and lifestyle modifications concurrently, per American Gastroenterological Association recommendations 2
• Consider 24-hour esophageal pH monitoring if empiric therapy fails 2

When Pericardial Pathology is Suspected

• Hiccups with other compression symptoms suggest pericardial effusion compressing the phrenic nerve 2
• Obtain chest X-ray and echocardiography immediately, as recommended by the European Society of Cardiology 2
• Treatment targets the underlying pericardial disease rather than the hiccups themselves 2

Second-Line Pharmacological Options

Metoclopramide

• The American Society of Clinical Oncology recommends metoclopramide as a second-line agent based on randomized controlled trial evidence 2
• The National Comprehensive Cancer Network also supports metoclopramide as an alternative treatment 2
• Particularly effective for peripheral causes of hiccups (versus central causes) 3

Other Pharmacological Agents

• Baclofen is the drug of choice for central causes of persistent hiccups (such as brain tumors or traumatic brain injury) 3, 2
• Gabapentin has demonstrated efficacy in persistent hiccups 4
• Midazolam may be useful specifically in terminal illness cases 3

Non-Pharmacological Interventions

Simple Physical Maneuvers (First Attempt)

• Measures that stimulate the uvula or pharynx are simple and often effective 5
• Techniques that disrupt diaphragmatic respiratory rhythm can terminate benign, self-limited hiccups 5
• Breath-holding maneuvers should be attempted before pharmacological intervention 3

Advanced Interventional Procedures

• Vagal or phrenic nerve block or stimulation should be considered in medication-refractory cases 3
• Acupuncture has been reported as successful in severe cases 4
• Intradermal injection of thiocolchicoside and lidocaine at the epigastric region has shown success in case reports, though this is not standard practice 6

Critical Clinical Considerations

Consequences of Untreated Persistent Hiccups

• Weight loss develops from prolonged hiccups 2
• Depression is a recognized complication 2
• Additional consequences include insomnia and fatigue 6

Central Nervous System Causes to Evaluate

• Brain tumors can cause hiccups and require imaging 2
• Traumatic brain injury is a central nervous system cause 2
• Stroke and space-occupying lesions involving the hiccup reflex arc require identification for potential ablative treatment 4

Treatment Algorithm Summary

1. Attempt simple physical maneuvers first (breath-holding, pharyngeal stimulation) 5, 3
2. If GERD suspected: Start high-dose PPI with lifestyle modifications 2
3. If no response or cause unknown: Initiate chlorpromazine 25-50 mg TID-QID 1
4. If central cause identified: Use baclofen instead of chlorpromazine 3
5. If peripheral cause or chlorpromazine fails: Add or switch to metoclopramide 2, 3
6. If medication-refractory: Consider nerve block or stimulation procedures 3

Common Pitfall

Do not delay pharmacological treatment beyond 48 hours of persistent symptoms, as this defines the transition from acute to persistent hiccups requiring medical intervention 4. The reflex arc involves peripheral phrenic, vagal, and sympathetic pathways with central midbrain modulation, meaning any irritant along this pathway can perpetuate the condition 4.