# 081 Management of Hiccups, 2nd ed


Author(s): Chad Farmer MD

Background   Hiccups (singultus) are distressing to patients and families; when chronic, they diminish quality of life. A hiccup is an involuntary reflex involving the respiratory muscles of the chest and diaphragm, mediated by the phrenic and vagus nerves and a central (brainstem) reflex center. A single episode can last for a few seconds to as long as several days. If they last longer than 48 hours hiccups are termed persistent; longer than one month, intractable. Etiologies range from stress/excitement to cancer, myocardial infarction, esophageal or gastric distension, liver disease, uremia, IV steroids, CNS lesions, and idiopathic. Irritation of the vagus nerve or diaphragm is a common pathophysiologic mechanism.

Management   Once hiccups have lasted beyond a time-limited annoyance, deciding on therapeutic intervention should be based on a thorough clinical assessment and, if possible, treatment directed at the underlying cause. A thorough history, review of medications, focused review of systems, and physical exam may help guide initial choice of treatment. Many drug and non-drug treatments have been used, but there is little evidence of any one superior approach to management; virtually all current data are anecdotal. The patient’s prognosis, current level of function, and potential adverse effects from any proposed treatment should be considered.

Pharmacologic Therapy

  • Anti-Psychotics: Chlorpromazine – the only FDA approved drug for hiccups. Dose: 25-50 mg PO TID or QID. Can also be given by slow IV infusion (25-50 mg in 500-1000 ml of NS over several hours). Haloperidol – a useful alternative to chlorpromazine; give a 2-5 mg (SubQ/PO) loading dose followed by 1-4 mg PO TID.
  • Anti-Convulsants: Gabapentin – at doses of 300-400 TID has been described as effective in multiple case reports. Phenytoin – reportedly effective in patients with a CNS etiology of their hiccups. Dose: 200 mg slow IV push followed by 300 mg PO daily. Others: Valproic Acid and Carbamazepine have been reported to work for selected patients.
  • Miscellaneous: Baclofen – the only drug studied in a double blind randomized controlled study for treatment of hiccups. 5 mg PO q8 hours did not eliminate hiccups but did provide symptomatic relief in some patients. Metoclopramide – 10 mg PO QID is an option, especially if stomach distension is the etiology. Nifedipine – 10 mg BID with gradual increase up to 20 mg TID has been suggested as a relatively safe alternative if other interventions have failed. Other drugs that have been tried with very limited success include: amitriptyline, sertraline, inhaled lidocaine, ketamine, edrophonium, and amantidine.

Non-Pharmacologic Therapy    There are many well known, time-honored home remedies: gargling with water, biting a lemon, swallowing sugar, or producing a fright response. Other approaches are directed at a) vagal stimulation such as carotid massage or valsalva maneuver; b) interruption of phrenic nerve transmission via rubbing over the 5th cervical vertebrae; or c) interrupting the respiratory cycle through sneezing, coughing, breath holding, hyperventilation, or breathing into a paper bag. Other interventions such as acupuncture, diaphragmatic pacing electrodes, or surgical ablation of the reflex arc can be considered when other treatments fail.


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Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition was edited by Drew A Rosielle and published October 2007. Current version re-copy-edited April 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Farmer C. Management of Hiccups, 2nd Edition. Fast Facts and Concepts. October 2007; 81. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_081.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non-Pain Symptoms and Syndromes