What are the treatment options for chronic hiccups?

Treatment of Chronic Hiccups

For chronic hiccups (lasting >48 hours), initiate chlorpromazine 25-50 mg three to four times daily as first-line pharmacotherapy, as it is the only FDA-approved medication for intractable hiccups. 1

Initial Assessment and Underlying Cause Management

Before initiating pharmacotherapy, identify and treat potential underlying causes:

• If GERD is suspected, start high-dose proton pump inhibitor (PPI) therapy immediately, as response may take 2 weeks to several months 2, 3
• Implement antireflux diet and lifestyle modifications concurrently: eliminate high-fat foods, coffee, tea, soda, chocolate, mints, citrus products, and alcohol; avoid smoking and vigorous exercise that increases intra-abdominal pressure 3
• Consider imaging (chest X-ray, echocardiography) if pericardial effusion or thoracic pathology is suspected, as phrenic nerve compression can cause hiccups 2
• Evaluate for central nervous system causes (brain tumors, traumatic brain injury) and peripheral causes (myocardial ischemia, herpes infection) 2, 4, 5

Pharmacological Treatment Algorithm

First-Line: Chlorpromazine

• Dosage: 25-50 mg orally three to four times daily 1
• If symptoms persist for 2-3 days, consider parenteral therapy 1
• Monitor closely for hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 2
• This is the only FDA-approved medication specifically indicated for intractable hiccups 1

Second-Line: Metoclopramide

• Recommended by the American Society of Clinical Oncology as a second-line agent 2
• Add metoclopramide (10 mg four times daily) to PPI therapy if GERD-related hiccups persist despite acid suppression alone 3
• Consider switching from H2-antagonist to PPI if patient was on H2-blocker, as proton pump inhibition may be effective when H2-antagonism has failed 3

Alternative Agents (When First-Line Fails)

• Baclofen: Emerging as a safe and often effective treatment for chronic hiccups 5, 6, 7
• Gabapentin: Considered a neuromodulatory therapy option 4
• Important caveat: Baclofen's commonest side effect is sedation; insomnia, dizziness, weakness, ataxia, and confusion can also occur. Following regular use, abrupt discontinuation can lead to withdrawal symptoms including seizures—gradual discontinuation is mandatory 6

Treatment Intensification for GERD-Related Hiccups

If initial PPI therapy is insufficient:

1. Add prokinetic therapy (metoclopramide) to PPI if symptoms persist 3
2. Consider 24-hour esophageal pH monitoring if empiric therapy is unsuccessful 2
3. Surgical intervention criteria: Consider antireflux surgery only if:
   • 24-hour esophageal pH monitoring before treatment was positive
   • Patient fits clinical profile suggesting GERD as likely cause
   • Hiccups have not improved after minimum 3 months of intensive medical therapy
   • Serial pH monitoring shows medical therapy has failed to control reflux
   • Patient reports unsatisfactory quality of life 3

Critical Warnings

• Untreated persistent hiccups can lead to weight loss, depression, sleep deprivation, and fatigue 2, 5, 8
• Chlorpromazine requires careful monitoring in elderly patients who are more susceptible to hypotension and neuromuscular reactions; dosage should be in the lower range and increased gradually 1
• Maximum improvement with chlorpromazine may not be seen for weeks or even months; continue optimum dosage for 2 weeks before adjusting 1

Non-Pharmacological Approaches

While pharmacotherapy is primary for chronic hiccups, non-pharmacological measures may be attempted concurrently:

• Nerve blockade, pacing, and acupuncture have shown success in some cases 4
• Intradermal injection (thiocolchicoside and lidocaine mixture) has been reported as an alternative method in refractory cases 8