Treatment of Incessant Hiccups
For adults with incessant hiccups, chlorpromazine 25-50 mg orally three to four times daily is the first-line pharmacological treatment, as it is the only FDA-approved medication for this indication and recommended by major medical societies. 1, 2
Initial Management Approach
Non-Pharmacological Interventions (First Attempt)
- Physical maneuvers stimulating the vagus nerve should be attempted first, including Larson's maneuver (pulling the tongue forward) to disrupt diaphragmatic rhythm 3, 1
- Simple measures that stimulate the uvula/pharynx or disrupt respiratory rhythm can terminate self-limited hiccups and may work for persistent cases 4
- These maneuvers are simple, safe, and should be tried before pharmacological intervention 4
Pharmacological Treatment (When Physical Maneuvers Fail)
Chlorpromazine remains the gold standard:
- Dosing: 25-50 mg orally three to four times daily 1, 2
- If symptoms persist for 2-3 days on oral therapy, parenteral administration is indicated: 25-50 mg IM 2, 5
- For severe refractory cases, slow IV infusion can be used: 25-50 mg in 500-1000 mL saline with patient supine, monitoring blood pressure closely 5
Critical monitoring requirements:
- Watch for sedation, hypotension, and extrapyramidal symptoms 1
- Elderly patients require lower doses and closer observation due to increased susceptibility to hypotension and neuromuscular reactions 2
- Dosage should be increased more gradually in debilitated or emaciated patients 2
Alternative Pharmacological Options
When chlorpromazine is contraindicated or ineffective, consider:
- Gabapentin or baclofen as second-line agents 6
- Metoclopramide (prokinetic agent) 6, 4
- Serotonergic agonists or lidocaine in select cases 6
Special Considerations
For Cancer Patients
- Consider opioid rotation if the patient is on opioids, as some opioids may trigger hiccups 1
- Trial demulcents (simple linctus syrup) initially, then proceed to opioid derivatives titrated to acceptable side effects if unsuccessful 1
Perioperative/Anesthesia Setting
- Propofol 1-2 mg/kg IV can be considered for hiccups during anesthesia, ensuring proper depth before airway manipulation 3
Refractory Cases
- Nerve blockade (phrenic nerve block) may be attempted, though evidence shows variable success 7
- Acupuncture has been studied but lacks high-quality evidence for efficacy 8
- Short-term positive pressure ventilation with muscle relaxants has been reported successful in isolated cases 7
Evidence Quality Caveat
The evidence base for hiccup treatment is notably weak - a Cochrane review found insufficient high-quality evidence to guide treatment, with no RCTs meeting inclusion criteria for pharmacological interventions 8. Despite this, chlorpromazine's FDA approval and consistent recommendation across medical literature makes it the most defensible first-line choice 1, 2, 5.
Common Pitfalls to Avoid
- Do not delay chlorpromazine in truly persistent cases (>48 hours) after simple maneuvers fail - prolonged hiccups significantly impact quality of life causing depression, weight loss, insomnia, and fatigue 9
- Do not use subcutaneous injection of chlorpromazine - inject deep IM into upper outer quadrant of buttock 5
- Avoid injecting undiluted chlorpromazine into veins except for specific indications (severe hiccups, surgery, tetanus) 5