What is the first line of treatment for hiccups in a healthy adult patient with no underlying medical conditions?

Treatment of Hiccups in Healthy Adults

For first-line treatment of hiccups in a healthy adult, begin with simple physical maneuvers that stimulate the pharynx or disrupt respiratory rhythm, and if hiccups persist beyond 48 hours, initiate pharmacotherapy with chlorpromazine as the primary agent or metoclopramide as an alternative. 1, 2

Initial Management: Physical Maneuvers

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

• Pharyngeal stimulation techniques are effective and include measures that stimulate the uvula or pharynx, such as swallowing granulated sugar, drinking cold water, or breath-holding maneuvers 1
• Respiratory rhythm disruption through techniques like holding breath, breathing into a paper bag, or performing the Valsalva maneuver can terminate benign hiccup episodes 1
• These simple measures often speed resolution of otherwise self-limited hiccups and may also terminate persistent cases 1

Pharmacologic Treatment: When Physical Maneuvers Fail

Definition of Persistent vs. Intractable Hiccups

• Persistent hiccups are defined as episodes lasting beyond 48 hours 3
• Intractable hiccups are episodes lasting longer than 2 months 3
• Drug therapy becomes necessary when simple maneuvers fail to resolve persistent hiccups 1

First-Line Pharmacotherapy

Chlorpromazine remains the most widely employed and established first-line pharmacologic agent:

• Dosing for intractable hiccups: 25-50 mg three to four times daily 4
• Chlorpromazine is one of the two most widely employed agents for hiccup treatment, with extensive historical use 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated 4

Metoclopramide serves as an alternative first-line agent:

• This is the other most widely employed drug alongside chlorpromazine 1
• Particularly useful given that gastroesophageal reflux disease (GERD) is the most common underlying cause of persistent hiccups 5

Alternative Pharmacologic Options

Baclofen has emerged as a safe and effective treatment option:

• Recent evidence supports baclofen as a safe alternative when traditional agents fail 2
• Also included in the pharmacotherapy armamentarium alongside gabapentin, serotonergic agonists, prokinetics, and lidocaine 3

Addressing Underlying Causes

When to Investigate Further

Consider underlying pathology when hiccups become persistent (>48 hours):

• Persistent hiccups may be a sign of underlying pathology requiring investigation 5
• The most common cause is GERD, followed by gastric/duodenal ulcers, gastritis, and esophagitis 5, 2

Proton Pump Inhibitor Therapy

Based on the high prevalence of GERD as an etiology, first-line therapy should include a proton pump inhibitor (PPI):

• Studies demonstrate that initial therapy should involve a PPI with appropriate gastrointestinal consultation 5
• Upper gastrointestinal investigations (endoscopy, pH monitoring, manometry) should be included systematically in the diagnostic evaluation of chronic hiccup patients 2

Clinical Algorithm

1. Acute hiccups (<48 hours): Physical maneuvers (pharyngeal stimulation, respiratory rhythm disruption) 1

2. Persistent hiccups (>48 hours):

   • Initiate PPI therapy for presumed GERD 5
   • Add chlorpromazine 25-50 mg TID-QID or metoclopramide 4, 1
   • Consider GI consultation 5

3. Refractory cases:

   • Trial of baclofen, gabapentin, or other alternative agents 2, 3
   • Explore central causes if symptoms persist despite treatment 5
   • Consider non-pharmacological approaches (nerve blockade, acupuncture) 3

Important Caveats

• Most hiccup episodes are self-limited and resolve spontaneously without medical intervention 6, 2
• Elderly patients require lower dosages of chlorpromazine and closer monitoring for hypotension and neuromuscular reactions 4
• Nearly 4,000 patients are admitted to US hospitals annually for hiccups, indicating this is not merely a trivial complaint 5
• Intractable hiccups can cause serious consequences including depression, weight loss, and sleep deprivation 2
• The evidence base relies heavily on anecdotal experience rather than controlled clinical studies, making treatment somewhat empirical 1