Treatment for Hiccups
For intractable hiccups, chlorpromazine 25-50 mg orally three to four times daily is the FDA-approved first-line pharmacological treatment, while acute self-limited hiccups can be managed with simple physical maneuvers targeting the vagus nerve. 1
Initial Assessment and Classification
Hiccups must be categorized by duration to guide treatment intensity 2:
- Acute hiccups: Self-limited episodes lasting less than 48 hours
- Persistent hiccups: Episodes lasting 48 hours to 2 months
- Intractable hiccups: Episodes persisting beyond 2 months
Identify underlying causes immediately, as persistent hiccups can indicate serious pathology including pericardial effusion compressing the phrenic nerve, brain tumors, traumatic brain injury, or gastroesophageal reflux disease 3, 4.
Treatment Algorithm
Acute Hiccups (< 48 hours)
Start with non-pharmacological vagal stimulation maneuvers 5, 6:
- Larson's maneuver: Apply deep pressure with the middle finger of each hand in the "laryngospasm notch" between the posterior border of the mandible and mastoid process while displacing the mandible forward in a jaw thrust 7, 8
- Suboccipital release: Apply gentle traction and pressure to the posterior neck, stretching suboccipital muscles and fascia to decompress the vagus and phrenic nerves 6
- Pharyngeal stimulation: Stimulate the uvula or pharynx 5
- Respiratory rhythm disruption: Breath-holding maneuvers 2
Persistent Hiccups (48 hours to 2 months)
If gastroesophageal reflux disease is suspected as the cause, initiate high-dose proton pump inhibitor therapy with response time variable from 2 weeks to several months 3. Implement antireflux diet and lifestyle modifications concurrently 3.
If partial or no improvement occurs with PPI therapy, add prokinetic therapy such as metoclopramide 3. Consider 24-hour esophageal pH monitoring if empiric therapy is unsuccessful 3.
For persistent hiccups without clear GERD etiology, metoclopramide is recommended as a second-line pharmacological agent 3.
Intractable Hiccups (> 2 months)
Chlorpromazine is the FDA-approved treatment for intractable hiccups 1:
- Dosing: 25-50 mg orally three to four times daily 1
- If symptoms persist for 2-3 days on oral therapy, parenteral therapy is indicated 1
- Maintenance therapy may be necessary for some patients after several weeks 1
Critical warnings about chlorpromazine: This medication can cause hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation 3. Elderly patients are more susceptible to hypotension and neuromuscular reactions and should be observed closely with lower initial dosages 1.
Perioperative or Anesthesia-Related Hiccups
For hiccups occurring during anesthesia or post-extubation, propofol 1-2 mg/kg IV may be effective 7, 8. Ensure proper depth of anesthesia before airway manipulation 8.
Apply continuous positive airway pressure with 100% oxygen using a reservoir bag and facemask while ensuring upper airway patency, and avoid unnecessary upper airway stimulation 7.
Consequences of Untreated Persistent Hiccups
Failure to treat persistent hiccups can lead to significant morbidity including weight loss, depression, insomnia, and fatigue 3, 9, 4. These complications underscore the importance of aggressive treatment when hiccups persist beyond 48 hours.
Alternative Pharmacological Options
When first-line treatments fail 2, 5:
- Gabapentin
- Baclofen
- Serotonergic agonists
- Lidocaine
Diagnostic Imaging Considerations
If pericardial or thoracic pathology is suspected (suggested by local compression symptoms), obtain chest X-ray and echocardiography 3. Pericardial effusion compressing the phrenic nerve can manifest as hiccups 3.
Common Pitfalls
Do not delay treatment of persistent hiccups beyond 48 hours, as they may indicate serious underlying pathology requiring specific intervention 4. The reflex arc involves peripheral phrenic, vagal, and sympathetic pathways with central midbrain modulation—any irritant along this pathway can cause hiccups 2.
Avoid using chlorpromazine in elderly or debilitated patients without dose adjustment and close monitoring for hypotension and extrapyramidal symptoms 1.