What is the treatment for intractable hiccups?

Treatment of Intractable Hiccups

Chlorpromazine 25-50 mg three to four times daily is the first-line pharmacological treatment for intractable hiccups, as it is the only FDA-approved medication for this indication. 1, 2

First-Line Pharmacological Treatment

Chlorpromazine remains the gold standard for intractable hiccups (defined as lasting >48 hours or >2 months for truly intractable cases). 1, 3

Dosing and Administration

• Oral route: Start with 25-50 mg three to four times daily 1, 2
• If symptoms persist for 2-3 days on oral therapy, escalate to intramuscular administration: 25-50 mg IM 4
• For refractory cases, slow IV infusion may be used: 25-50 mg in 500-1000 mL saline with patient flat in bed, monitoring blood pressure closely 4

Critical Monitoring Requirements

• Monitor for sedation, hypotension, and extrapyramidal symptoms throughout treatment 1
• Keep patients lying down for at least 30 minutes after IM injection due to hypotensive effects 4
• Elderly patients require lower doses and closer observation as they are more susceptible to adverse effects 2, 4

Alternative Pharmacological Options

When chlorpromazine is contraindicated or ineffective, consider:

• Gabapentin - acts on the reflex arc 3
• Baclofen - centrally acting agent 3, 5
• Metoclopramide - peripherally acting prokinetic agent 3, 5

Non-Pharmacological Interventions

Physical Maneuvers (First Attempt)

• Larson's maneuver (pulling tongue forward) stimulates the vagus nerve and disrupts diaphragmatic rhythm 1
• Vagal stimulation techniques (carotid sinus massage, Valsalva maneuver) work by overstimulating the vagus nerve 5

Interventional Procedures (For Refractory Cases)

• Phrenic nerve blockade - though success rates vary 5, 6
• Stellate ganglion block - emerging evidence shows temporary relief (ultrasound-guided with ropivacaine/lidocaine combination) 6
• Vagus nerve stimulator (VNS) placement - novel surgical option for medical refractory cases with partial success reported 5
• Acupuncture - though evidence quality is poor 7

Special Considerations

Cancer Patients

• Consider opioid rotation if the patient is on opioids, as certain opioids may trigger hiccups 1
• For lung cancer patients specifically, trial demulcents (simple linctus syrup) first, then proceed to opioid derivatives titrated to acceptable side effects if unsuccessful 1

Treatment Algorithm

1. Initial approach: Attempt physical maneuvers (Larson's maneuver, vagal stimulation) 1, 5
2. First-line medication: Chlorpromazine 25-50 mg PO three to four times daily 1, 2
3. Escalation (if persistent 2-3 days): Chlorpromazine 25-50 mg IM 4
4. Refractory cases: Consider alternative medications (gabapentin, baclofen) or interventional procedures (nerve blocks, VNS) 3, 5, 6

Critical Pitfalls to Avoid

• Do not use subcutaneous injection of chlorpromazine 4
• Avoid injecting undiluted chlorpromazine into veins - IV route is reserved only for severe refractory hiccups with proper dilution 4
• Do not overlook underlying pathology - intractable hiccups frequently result from lesions involving the hiccup reflex arc (central causes: stroke, tumors; peripheral causes: GERD, myocardial ischemia, herpes infection) and require correct diagnosis for definitive treatment 3
• The evidence base for non-pharmacological interventions is extremely limited, with a 2013 Cochrane review finding insufficient evidence to guide treatment due to lack of high-quality RCTs 7