Management of Hiccups
For persistent hiccups lasting beyond 48 hours, initiate pharmacological treatment with chlorpromazine 25-50 mg three to four times daily as first-line therapy, as this is the only FDA-approved medication for intractable hiccups. 1
Initial Assessment and Simple Interventions
Attempt physical maneuvers first for acute hiccups including breath-holding, pharyngeal stimulation, or measures that disrupt diaphragmatic rhythm, as these simple interventions often terminate benign, self-limited episodes. 2, 3
Identify potential underlying causes by evaluating for gastroesophageal reflux disease (GERD), central nervous system pathology (brain tumors, traumatic brain injury), pericardial effusion compressing the phrenic nerve, or medication-induced causes. 4
Obtain imaging studies (chest X-ray, echocardiography) if pericardial or thoracic pathology is suspected, particularly when hiccups present with other compressive symptoms. 4
Pharmacological Management Algorithm
First-Line Treatment
Administer chlorpromazine 25-50 mg orally three to four times daily for intractable hiccups, which is the FDA-approved dosage for this indication. 1
Monitor for adverse effects including hypotension, sedation, extrapyramidal symptoms, and QT interval prolongation when using chlorpromazine. 4
If symptoms persist for 2-3 days on oral therapy, consider transitioning to parenteral chlorpromazine administration. 1
Cause-Specific Treatment
For GERD-related hiccups, initiate high-dose proton pump inhibitor (PPI) therapy with response time variable from 2 weeks to several months, and add prokinetic therapy (such as metoclopramide) if partial or no improvement occurs. 4
Implement antireflux diet and lifestyle modifications concurrently with PPI therapy for patients with suspected GERD-induced hiccups. 4
Second-Line Pharmacological Options
Consider metoclopramide as a second-line agent when chlorpromazine is contraindicated or ineffective, though this is not FDA-approved specifically for hiccups. 4, 2
For central causes of persistent hiccups (CNS pathology), baclofen may be more effective than peripheral-acting agents. 5
Important Clinical Considerations
Recognize that untreated persistent hiccups can lead to significant morbidity including weight loss and depression, making prompt treatment essential. 4
Persistent hiccups are defined as episodes lasting beyond 48 hours, while intractable hiccups persist beyond 2 months, requiring more aggressive management. 3, 6
In elderly or debilitated patients, use lower initial dosages of chlorpromazine and increase gradually, as these patients are more susceptible to hypotension and neuromuscular reactions. 1
Refractory Cases
For medication-refractory cases, consider interventional procedures such as vagal or phrenic nerve block or stimulation. 5
In terminal illness, midazolam may be useful for managing persistent hiccups when other treatments have failed. 5
Maximum improvement may not be seen for weeks, so continue optimum dosage for at least 2 weeks before declaring treatment failure, then gradually reduce to the lowest effective maintenance level. 1