Treatment of Hiccups
For acute hiccups, start with physical maneuvers targeting the pharynx or disrupting respiratory rhythm; for persistent hiccups (>48 hours), initiate pharmacotherapy with baclofen or gabapentin as first-line agents, reserving chlorpromazine and metoclopramide for refractory cases. 1
Classification and Initial Approach
Hiccups are classified by duration, which determines management strategy 2, 3:
- Acute hiccups: <48 hours (usually self-limited, rarely require intervention)
- Persistent hiccups: 48 hours to 2 months
- Intractable hiccups: >2 months
Non-Pharmacologic Management
Physical Maneuvers (First-Line for Acute Hiccups)
Measures that stimulate the uvula/pharynx or disrupt diaphragmatic rhythm should be attempted first for acute episodes. 4 These include:
- Pharyngeal stimulation techniques (swallowing granulated sugar, sipping ice water, gargling) 4, 5
- Respiratory maneuvers (breath-holding, Valsalva maneuver, breathing into a paper bag) 4, 3
- Handheld fan directed at the face (proven effective in similar reflex conditions) 6
These interventions work by interrupting the reflex arc involving the phrenic nerve, vagus nerve, and central midbrain pathways 2.
Pharmacologic Management
When to Initiate Drug Therapy
Pharmacotherapy becomes necessary when 4, 3:
- Hiccups persist beyond 48 hours
- Episodes are severely bothersome or interfere with quality of life
- Physical maneuvers fail to provide relief
First-Line Pharmacologic Agents
Baclofen and gabapentin are recommended as first-line therapy based on efficacy and superior safety profiles during long-term use. 1
Baclofen 1:
- Supported by small randomized, placebo-controlled trials
- Lower risk of side effects compared to neuroleptics during prolonged therapy
- Acts on the reflex arc centrally
Gabapentin 1:
- Supported by observational data showing effectiveness
- Favorable side effect profile for long-term management
- Modulates neural pathways involved in the hiccup reflex
Second-Line Pharmacologic Agents
Metoclopramide 1:
- Supported by small randomized, placebo-controlled trials
- Prokinetic action addresses gastric overdistension (most common identifiable cause) 3
- Reserve for cases where first-line agents fail
- FDA-labeled indication for intractable hiccups
- Dosing: 25-50 mg orally three to four times daily 7
- If symptoms persist 2-3 days, parenteral therapy indicated 7
- Most widely employed agent historically but higher side effect burden 4
- Reserve due to risk of hypotension and neuromuscular reactions, especially in elderly 7
Alternative Pharmacologic Options
Other agents with reported efficacy based on observational data 2, 1:
- Serotonergic agonists
- Lidocaine
- Anti-reflux therapy (empirical trial appropriate given gastroesophageal reflux as common cause) 1, 3
Treatment Algorithm
Acute hiccups (<48 hours): Physical maneuvers; observe for spontaneous resolution 4, 3
Persistent hiccups (>48 hours):
Refractory persistent/intractable hiccups:
Severe intractable cases: Consider non-pharmacologic interventions including nerve blockade, pacing, or acupuncture 2
Critical Caveats
- Persistent or intractable hiccups can indicate serious underlying pathology (neurological, cardiovascular, pulmonary, infectious disorders) requiring thorough evaluation 3
- No adequately powered, well-designed trials exist for hiccup treatment; recommendations based on limited data 1
- Chlorpromazine requires careful monitoring for hypotension and extrapyramidal symptoms, particularly in elderly and debilitated patients 7
- Treatment directed at underlying condition is most effective when identifiable cause exists 1