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, including Larson's maneuver (pulling the tongue forward), which disrupts diaphragmatic rhythm and stimulates the vagus nerve 2, 3
• Other physical maneuvers that stimulate the uvula or pharynx may help terminate benign, self-limited hiccups 4
• These measures are simple, safe, and often effective for acute episodes lasting less than 48 hours 5, 4

When to Escalate to Pharmacotherapy

• Persistent hiccups (lasting >48 hours) or intractable hiccups (lasting >2 months) require pharmacological intervention 6
• Physical maneuvers alone are typically insufficient for prolonged cases 5, 4

Pharmacological Treatment

First-Line: Chlorpromazine

• Dosing: 25-50 mg orally three to four times daily 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated 1
• This is the only FDA-approved medication specifically for intractable hiccups 1
• Chlorpromazine is widely recognized as one of the most effective agents for this purpose 4, 6

Important monitoring requirements:

• Watch for sedation, hypotension, and extrapyramidal symptoms 2
• Use lower doses in elderly, emaciated, or debilitated patients 1
• Elderly patients are more susceptible to hypotension and neuromuscular reactions and require closer observation 1

Alternative Pharmacological Options

If chlorpromazine is contraindicated or ineffective:

• Baclofen has emerged as a safe and often effective alternative 5, 6
• Gabapentin is another option for refractory cases 6, 7
• Metoclopramide can be used, particularly when gastrointestinal pathology is suspected 5, 4, 6

Special Consideration for Cancer Patients

• Consider opioid rotation if the patient is on opioids, 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

Evaluation for Underlying Causes

Critical caveat: Prolonged hiccups warrant investigation for underlying pathology, as they can indicate serious conditions including:

• Myocardial infarction, stroke, or brain tumors 5, 6
• Gastroesophageal reflux disease, gastritis, or peptic ulcer disease 5, 6
• Renal failure, prostate cancer, or post-abdominal surgery complications 5
• Drug-induced causes (anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy) 6

Upper gastrointestinal investigations (endoscopy, pH monitoring, manometry) should be included systematically, as gastric/duodenal ulcers and esophageal pathology are commonly observed in chronic hiccup patients 5

Refractory Cases

For medical refractory intractable hiccups causing significant morbidity (anorexia, insomnia, depression, weight loss):

• Phrenic nerve blockade or surgical intervention may be considered 6, 7
• Vagus nerve stimulator (VNS) placement is an emerging surgical option with reported partial success 7
• Unconventional therapies including acupuncture, hypnosis, and nerve pacing have been attempted with variable success 6, 7