What is the treatment for hiccups (singultus)?

Treatment of Hiccups (Singultus)

For acute hiccups lasting less than 48 hours, simple physical maneuvers that stimulate the pharynx or disrupt respiratory rhythm should be attempted first, while persistent hiccups (>48 hours) require chlorpromazine as the primary pharmacological agent, with doses of 25-50 mg three to four times daily. 1, 2

Initial Assessment and Classification

Hiccups must be classified by duration to guide treatment intensity 3, 4:

• Acute hiccups: Self-limited episodes lasting less than 48 hours 3, 4
• Persistent hiccups: Episodes lasting 48 hours to 2 months 3, 4
• Intractable hiccups: Episodes lasting longer than 2 months 3, 4

The most common identifiable cause of acute hiccups is gastric overdistension, followed by gastroesophageal reflux and gastritis 4. When hiccups persist beyond 48 hours, they may indicate serious underlying pathology including myocardial infarction, brain tumors, renal failure, or abdominal surgery complications 5.

Treatment Algorithm

Step 1: Physical Maneuvers (First-Line for Acute Hiccups)

Simple physical maneuvers that stimulate the uvula/pharynx or disrupt diaphragmatic rhythm should be attempted first for acute hiccups. 2 These measures often speed resolution of benign, self-limited hiccups and may terminate persistent episodes 2.

Effective physical maneuvers include 2, 3:

• Pharyngeal stimulation (stimulating the uvula or back of throat)
• Breath-holding techniques
• Measures to disrupt respiratory rhythm

Step 2: Identify and Treat Underlying Causes

Upper gastrointestinal investigations should be performed systematically in patients with persistent or intractable hiccups, as gastric/duodenal ulcers, gastritis, esophageal reflux, and esophagitis are commonly observed. 5 Gastroesophageal reflux may be underestimated as a cause and can be successfully treated with anti-reflux therapy 6.

For hiccups due to gastroesophageal reflux, treatment of the underlying reflux with appropriate therapy (proton pump inhibitors or H2-blockers) can resolve hiccups without requiring antisingultus medications 6.

Step 3: Pharmacological Therapy (For Persistent/Intractable Hiccups)

Chlorpromazine is the primary pharmacological agent for intractable hiccups and is one of the two most widely employed drugs for this purpose. 2, 5

Chlorpromazine Dosing (FDA-Approved)

For intractable hiccups 1:

• Oral dose: 25-50 mg three to four times daily
• If symptoms persist for 2-3 days on oral therapy, parenteral therapy is indicated 1
• In elderly patients, use lower dosages as they are more susceptible to hypotension and neuromuscular reactions 1

Common pitfall: Do not underdose chlorpromazine in non-elderly adults—the full 25-50 mg dose three to four times daily is necessary for efficacy 1.

Alternative Pharmacological Agents

When chlorpromazine is contraindicated or ineffective 2, 3, 5:

• Metoclopramide: One of the two most widely employed agents alongside chlorpromazine 2
• Baclofen: Has emerged as a safe and often effective treatment for chronic hiccups 5
• Gabapentin: Effective pharmacotherapy option 3
• Other agents with reported efficacy include serotonergic agonists, prokinetics, and lidocaine 3

Step 4: Advanced Interventions (For Refractory Cases)

For severe, intractable cases unresponsive to pharmacotherapy 2, 3:

• Physical disruption of the phrenic nerve (nerve blockade or pacing) 2, 3
• Acupuncture 2, 3
• Hypnosis 2

Critical Clinical Caveats

Persistent or intractable hiccups can be a harbinger of serious medical pathology and should never be dismissed as benign without proper evaluation. 4 Detailed medical history and physical examination will often guide diagnostic investigations including abdominal ultrasound, chest CT, or brain CT scan 5.

Do not treat persistent hiccups empirically without investigating for underlying causes, as conditions such as myocardial infarction, stroke, brain tumors, and abdominal malignancies can present with hiccups as an early symptom 5, 4.

Upper gastrointestinal endoscopy, pH monitoring, and manometry should be included in the diagnostic evaluation systematically for persistent hiccups, as GI pathology is frequently identified 5.

Special Populations

Pediatric Patients (6 months to 12 years)

Chlorpromazine dosing for severe conditions 1:

• Oral: ¼ mg/lb body weight every 4-6 hours as needed (e.g., 10 mg every 4-6 hours for a 40 lb child)
• Chlorpromazine should generally not be used in pediatric patients under 6 months of age except where potentially lifesaving 1

Elderly Patients

Use lower dosages and increase gradually, as elderly patients are more susceptible to hypotension and neuromuscular reactions from chlorpromazine 1. Monitor closely and adjust dosage based on individual response 1.