What are the treatment options for hiccups?

Treatment for Hiccups

For intractable hiccups, chlorpromazine 25-50 mg three to four times daily is the FDA-approved first-line pharmacological treatment, while simple physical maneuvers should be attempted first for acute, self-limited episodes. 1

Initial Approach: Physical Maneuvers

For acute hiccups (lasting less than 48 hours), begin with non-pharmacological interventions that stimulate the vagus nerve or disrupt the hiccup reflex arc:

• Apply pressure between the posterior border of the mandible and mastoid process (similar to Larson's maneuver), which can terminate hiccups by vagal stimulation 2
• Other vagal stimulation techniques include pharyngeal stimulation or measures that disrupt diaphragmatic rhythm 3
• These simple maneuvers are often effective for benign, self-limited hiccups and should be the first-line approach 3

Pharmacological Treatment Algorithm

First-Line: Chlorpromazine

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

• Dosing: 25-50 mg orally three to four times daily 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated 1
• Important warnings: Can cause hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 4
• Use lower doses in elderly, emaciated, or debilitated patients who are more susceptible to adverse effects 1

Second-Line: Metoclopramide

When chlorpromazine is contraindicated or ineffective:

• Metoclopramide is recommended as a second-line agent based on randomized controlled trial evidence 4
• Particularly useful when gastroesophageal reflux disease (GERD) is suspected as the underlying cause 4

GERD-Related Hiccups

If GERD is the suspected etiology:

• Initiate high-dose proton pump inhibitor (PPI) therapy with response time variable from 2 weeks to several months 4
• Add prokinetic therapy (such as metoclopramide) if partial or no improvement occurs 4
• Implement antireflux diet and lifestyle modifications concurrently 4
• Consider 24-hour esophageal pH monitoring if empiric therapy is unsuccessful 4

Alternative Pharmacological Options

Based on research evidence when standard treatments fail:

• Baclofen has emerged as a safe and often effective treatment for chronic hiccups 5
• Gabapentin is another option supported by clinical experience 6

Special Situations

Perioperative/Anesthesia Setting

For hiccups occurring during anesthesia or post-extubation:

• Propofol 1-2 mg/kg IV may be effective 2, 7
• Ensure proper depth of anesthesia before airway manipulation 7
• Apply continuous positive airway pressure with 100% oxygen if associated with laryngospasm 2

Diagnostic Considerations

Before treating persistent hiccups (>48 hours), evaluate for underlying causes:

• Central nervous system pathology: Brain tumors, traumatic brain injury, stroke 4
• Thoracic/cardiac causes: Pericardial effusion compressing the phrenic nerve (obtain chest X-ray and echocardiography if suspected) 4
• Gastrointestinal causes: GERD, gastritis, peptic ulcer disease (consider upper endoscopy, pH monitoring, and manometry) 5
• Other causes include myocardial infarction, renal failure, medications (anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy) 6, 5

Clinical Pearls and Pitfalls

Untreated persistent hiccups can lead to significant morbidity:

• Weight loss, depression, sleep deprivation, and fatigue are common complications 4, 5
• Episodes lasting >48 hours are considered persistent; >2 months are intractable 6

Common pitfall: Failing to investigate underlying pathology in persistent cases. Upper gastrointestinal investigations should be included systematically as gastric/duodenal ulcers, gastritis, and esophageal reflux are commonly observed 5

Chlorpromazine precautions: Monitor closely for hypotension and extrapyramidal symptoms, particularly in elderly patients who require lower doses and closer observation 4, 1