Treatment of Hiccups
For first-line treatment of hiccups in adults without severe underlying conditions, start with simple physical maneuvers; if hiccups persist beyond 48 hours, initiate pharmacotherapy with chlorpromazine 25-50 mg three to four times daily, which is the only FDA-approved medication for intractable hiccups. 1
Initial Management: Physical Maneuvers
For acute, self-limited hiccups (lasting less than 48 hours), begin with non-pharmacological interventions that disrupt the reflex arc: 2, 3
- Pharyngeal stimulation techniques such as swallowing granulated sugar, drinking cold water rapidly, or stimulating the uvula can interrupt the hiccup reflex 2
- Respiratory maneuvers including breath-holding, breathing into a paper bag, or Valsalva maneuver may disrupt diaphragmatic rhythm 2, 3
- These simple measures often terminate benign hiccups without requiring medical intervention 4, 5
Pharmacological Treatment: When Physical Maneuvers Fail
First-Line: Chlorpromazine
Chlorpromazine remains the gold standard and only FDA-approved medication for intractable hiccups: 1, 6
- Oral dosing: 25-50 mg three to four times daily 1
- If symptoms persist after 2-3 days of oral therapy, switch to intramuscular administration: 25-50 mg IM 6
- For severe refractory cases requiring IV route: dilute 25-50 mg in 500-1000 mL saline and administer as slow infusion with patient supine, monitoring blood pressure closely 6
- Chlorpromazine is the most widely employed agent based on decades of clinical experience 2, 5
Important monitoring considerations:
- Watch for hypotension, particularly with parenteral administration—keep patient lying down for at least 30 minutes after IM injection 6
- Monitor for extrapyramidal symptoms 7
Second-Line: Metoclopramide
If chlorpromazine is contraindicated or ineffective, metoclopramide is an alternative: 7
- Dosing: 10 mg orally three to four times daily 7
- Acts as a prokinetic agent, particularly useful when gastroesophageal reflux is suspected as the underlying cause 7, 2
- Critical precautions: Limit duration of use due to tardive dyskinesia risk with prolonged therapy 7
- Have diphenhydramine available for potential dystonic reactions 7
- Avoid in patients with seizure disorders, GI bleeding, or GI obstruction 7
Alternative Pharmacological Options
For cases refractory to first-line agents: 4, 5
- Baclofen has emerged as a safe and often effective treatment, particularly for chronic cases 5
- Gabapentin may be considered 4
- Proton pump inhibitors should be added if GERD is suspected, as this is the most common underlying cause of persistent hiccups 8
Diagnostic Considerations for Persistent Hiccups
Hiccups lasting beyond 48 hours warrant investigation for underlying pathology: 4, 5, 8
- Gastrointestinal causes (most common): GERD, gastritis, peptic ulcer disease—consider upper endoscopy, pH monitoring 5, 8
- Central causes: stroke, brain tumors, CNS injury 4, 5
- Peripheral nerve irritation: phrenic or vagal nerve involvement from tumors, myocardial ischemia, herpes infection 4
- Metabolic/toxic: renal failure, medications (anti-Parkinson drugs, anesthetics, steroids, chemotherapy) 4, 5
Common Pitfalls to Avoid
- Do not dismiss persistent hiccups (>48 hours) as benign—they may signal serious underlying pathology requiring investigation 5, 8
- Avoid subcutaneous injection of chlorpromazine; use deep IM injection in upper outer quadrant of buttock 6
- Never inject undiluted chlorpromazine IV—always dilute to at least 1 mg/mL and administer slowly 6
- Do not continue metoclopramide indefinitely—the risk of tardive dyskinesia increases with prolonged use 7
- Recognize that intractable hiccups can cause serious morbidity including depression, weight loss, and sleep deprivation if left untreated 5
Refractory Cases
For truly intractable hiccups unresponsive to pharmacotherapy: 4, 2