What is the first-line treatment for hiccups in an adult patient with no underlying severe medical conditions?

Treatment of Hiccups in Adults

For acute, benign hiccups in adults without severe underlying conditions, begin with simple physical maneuvers that stimulate the pharynx or disrupt respiratory rhythm; if hiccups persist beyond 48 hours, initiate pharmacological therapy with baclofen or gabapentin as first-line agents, reserving metoclopramide and chlorpromazine for refractory cases. 1

Initial Approach: Physical Maneuvers

For self-limited hiccups (lasting less than 48 hours), simple physical interventions should be attempted first:

• Pharyngeal stimulation techniques such as stimulating the uvula or pharynx can disrupt the hiccup reflex arc and often terminate benign episodes 2
• Respiratory rhythm disruption through breath-holding maneuvers may speed resolution of acute hiccup bouts 2, 3
• These simple measures are appropriate for hiccups associated with gastric distention or alcohol intake, which typically resolve spontaneously 4

Pharmacological Treatment Algorithm

First-Line Agents (for persistent hiccups >48 hours)

Baclofen is the preferred initial pharmacological agent:

• Supported by randomized, placebo-controlled trial data 1
• Particularly effective for central causes of hiccups (stroke, brain lesions, CNS pathology) 3
• Safer profile for long-term use compared to neuroleptic agents 4, 1

Gabapentin as an alternative first-line option:

• Supported by observational data showing effectiveness 1
• Less likely to cause side effects during prolonged therapy 1
• Appropriate when baclofen is contraindicated or ineffective 1

Second-Line Agents

Metoclopramide for peripheral causes:

• Recommended as first choice when hiccups originate from peripheral irritation (gastroesophageal reflux, gastric distention, vagal/phrenic nerve irritation) 3
• Supported by small randomized controlled trial data 1
• Consider empirical anti-reflux therapy trial, as gastric ulcers, gastritis, and esophageal reflux are commonly observed in chronic hiccup patients 4

Chlorpromazine in reserve:

• FDA-approved for intractable hiccups at 25-50 mg three to four times daily 5
• One of the most widely employed agents historically 2
• Supported by observational data 1
• Higher risk of side effects (hypotension, neuromuscular reactions) particularly in elderly patients; requires close monitoring 5

Special Considerations

Palliative Care Context

• Midazolam may be useful in terminal illness when other agents have failed 3
• Focus on quality of life, as persistent hiccups can cause depression, weight loss, and sleep deprivation 4

Refractory Cases (intractable hiccups >2 months)

• Consider interventional procedures: vagal or phrenic nerve block or stimulation 3
• Acupuncture and nerve blockade have been reported successful in severe cases 2, 6

Critical Pitfalls to Avoid

• Do not delay pharmacological treatment beyond 48 hours if physical maneuvers fail, as prolonged hiccups significantly impact quality of life 4
• Avoid chlorpromazine as first-line in elderly or debilitated patients due to increased susceptibility to hypotension and neuromuscular reactions 5
• Do not overlook underlying causes: myocardial infarction, brain tumors, renal failure, and gastroesophageal pathology can all trigger persistent hiccups and require specific treatment 6, 4
• Recognize that standard neuroleptic agents carry higher side-effect burden during long-term therapy compared to baclofen or gabapentin 1

Evidence Quality Note

The systematic review reveals no adequately powered, well-designed trials for hiccup treatment 1. Recommendations are based on small randomized trials for baclofen and metoclopramide, with observational data supporting gabapentin and chlorpromazine 1. This evidence limitation necessitates individualized clinical judgment, but the weight of available data supports the algorithm presented above.