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

Treatment for Hiccups

For intractable hiccups in adults, chlorpromazine 25-50 mg three to four times daily is the first-line pharmacological treatment, as it is the only FDA-approved medication for this indication. 1

Initial Management Approach

Simple Physical Maneuvers (First-Line for Acute Hiccups)

• Vagal stimulation techniques should be attempted first for acute hiccups, including Larson's maneuver (pulling the tongue forward), drinking cold water, or Valsalva maneuver 2, 3, 4
• These maneuvers work by overstimulating the vagus nerve or disrupting diaphragmatic rhythm 2, 5
• Most acute hiccup episodes are self-limited and resolve with these simple interventions 6, 7

Pharmacological Treatment (For Persistent/Intractable Hiccups)

First-Line Medication

• Chlorpromazine 25-50 mg orally three to four times daily is the primary pharmacological treatment 2, 1
• This is the only FDA-approved medication specifically indicated for intractable hiccups 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration should be considered 1
• Monitor closely for side effects: sedation, hypotension, and extrapyramidal symptoms 2
• Elderly patients require lower initial doses with gradual titration due to increased susceptibility to hypotension and neuromuscular reactions 1

Alternative Pharmacological Options

• Baclofen has emerged as a safe and often effective alternative treatment for chronic hiccups 6, 8
• Gabapentin is another option for refractory cases 8, 4
• Metoclopramide can be used, particularly when gastroesophageal pathology is suspected 6, 5, 8

Special Considerations

Cancer Patients

• Consider opioid rotation if the patient is receiving opioid therapy, as certain opioids may trigger hiccups 2
• For lung cancer patients specifically, an initial trial with demulcents (simple linctus syrup) is recommended before escalating to opioid derivatives 2

Perioperative Setting

• Propofol (1-2 mg/kg IV) can be considered for hiccups during anesthesia or in the perioperative period, ensuring proper depth of anesthesia before airway manipulation 3

Diagnostic Evaluation for Persistent Hiccups

When hiccups persist beyond 48 hours, investigate for underlying pathology:

• Upper gastrointestinal causes are commonly identified: gastric/duodenal ulcers, gastritis, esophageal reflux, and esophagitis warrant systematic evaluation with endoscopy, pH monitoring, and manometry 6
• Central causes include stroke, space-occupying lesions, and brain injury requiring imaging 8
• Peripheral causes along the reflex arc include myocardial ischemia, tumors, herpes infection, and abdominal pathology 8
• Drug-induced hiccups from anti-parkinsonism drugs, anesthetic agents, steroids, or chemotherapy should be considered 8

Refractory Cases

Interventional Options

• Phrenic nerve blockade or resection may be attempted in medical refractory cases, though success is variable 4
• Vagus nerve stimulator (VNS) placement is an emerging surgical option for truly intractable cases unresponsive to all other therapies 4
• Unconventional therapies including acupuncture, hypnosis, and nerve pacing have been reported with uncertain efficacy 8, 4

Common Pitfalls

• Do not delay pharmacological treatment in persistent hiccups (>48 hours), as prolonged episodes can cause depression, weight loss, sleep deprivation, and significant morbidity 6, 4
• Avoid using chlorpromazine without monitoring for hypotension and extrapyramidal symptoms, particularly in elderly or debilitated patients 2, 1
• Do not overlook treatable underlying causes: gastroesophageal pathology is frequently missed and should be systematically evaluated 6