What is the treatment for hiccups?

Treatment of Hiccups

For intractable hiccups lasting more than 48 hours, chlorpromazine 25-50 mg three to four times daily is the FDA-approved first-line pharmacological treatment, though metoclopramide and baclofen are recommended as alternatives by major medical societies. 1

Initial Management Approach

Acute Hiccups (< 48 hours)

Start with simple physical maneuvers before considering pharmacotherapy, as most acute episodes resolve spontaneously within minutes. 2

• Apply pressure between the posterior border of the mandible and mastoid process (similar to Larson's maneuver) to terminate hiccups 3
• Stimulate the uvula or pharynx, or disrupt diaphragmatic respiratory rhythm 4
• These non-pharmacological measures are simple and often effective for benign, self-limited hiccups 4

Identify and Treat Underlying Causes

Before initiating empiric therapy, evaluate for treatable causes as hiccups may indicate serious underlying pathology. 2

Gastrointestinal causes (most common):

• If gastroesophageal reflux disease (GERD) is suspected, initiate high-dose proton pump inhibitor (PPI) therapy with response time variable from 2 weeks to several months 5
• Add prokinetic therapy such as metoclopramide if partial or no improvement occurs with PPI alone 5
• Implement antireflux diet and lifestyle modifications concurrently 5
• Consider 24-hour esophageal pH monitoring if empiric therapy is unsuccessful 5

Cardiovascular/thoracic causes:

• Hiccups with other local compression symptoms suggest pericardial effusion compressing the phrenic nerve 5
• Obtain chest X-ray and echocardiography if pericardial or thoracic pathology is suspected 5

Central nervous system causes:

• Brain tumors and traumatic brain injury can cause hiccups 5
• Consider neuroimaging in persistent cases without clear peripheral etiology 6

Pharmacological Treatment for Persistent/Intractable Hiccups

First-Line Agent

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

• Dosing: 25-50 mg three to four times daily orally 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 by the American Society of Clinical Oncology based on randomized controlled trial evidence. 5

• Consider metoclopramide as an alternative, particularly when GERD is suspected as the underlying cause 5
• Can be used as add-on therapy to PPI if partial response occurs 5

Baclofen is the treatment of choice when simple physical maneuvers and causal therapy fail or are impossible. 7

• Baclofen acts on the reflex arc and has demonstrated efficacy in stepwise management plans 7

Other Pharmacological Options

Additional agents with reported efficacy include: 6

• Gabapentin 6
• Serotonergic agonists 6
• Lidocaine 6

Special Situations

Perioperative/Anesthesia-Related Hiccups

For hiccups occurring during anesthesia or post-extubation, propofol 1-2 mg/kg IV may be effective. 3

• In severe cases associated with laryngospasm, follow the laryngospasm treatment algorithm including positive pressure ventilation with 100% oxygen 3
• Avoid airway stimulation which can worsen the condition 3

Non-Pharmacological Interventions for Refractory Cases

When pharmacotherapy fails: 6

• Nerve blockade (phrenic nerve) 6
• Pacing 6
• Acupuncture 6
• Interruption of the reflex arc may be considered as a last resort 7

Critical Pitfalls to Avoid

Do not dismiss persistent hiccups as benign without proper evaluation, as they can indicate serious underlying pathology. 2

• Untreated persistent hiccups can lead to weight loss and depression 5
• In tracheotomized patients, hiccups may cause alkalosis due to hyperventilation 7
• The respiratory effect is generally negligible in most patients 7

Do not delay treatment escalation in persistent cases, as prolonged hiccups can significantly impair quality of life. 5, 2