Management

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 is anecdotal. Once hiccups have gone 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. The patient's prognosis, current level of function and potential adverse effects from any proposed treatment should be considered.

Pharmacological

1. 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 500-1000cc of NS over several hours). Haloperidol - a useful alternative to chlorpromazine; give 2-5 mg (IM/po) loading dose followed by 1-4 mg po tid.
2. Anti-Convulsants: Phenytoin - reportedly effective in patients with a CNS etiology of their hiccups; dose: 200 mg slow IV push followed by 300 mg po qd. Others: Valproic Acid and Carbamazepine have been reported to work for selected patients.
3. Miscellaneous: Baclofen - The only drug studied in a double blind randomized controlled study for treatment of hiccups; 5 mg po q8H 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, inhaled lidocaine, ketamine, edrophonium, amantidine.

Non-Pharmacological

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: carotid massage or valsalva maneuver; b) interruption of phrenic nerve transmission via rubbing over the 5th cervical vertebrae; c) interrupting the respiratory cycle through sneezing, coughing, breath holding, hyperventilation, or breathing into a paper bag. Other interventions, acupuncture diaphragmatic pacing electrodes, or surgical ablation of the reflex arc, can be considered when other treatments fail.

References

Kolodzik PW, Eilers, MA: Hiccups (singultus): Review and approach to management. Ann Emerg Med 1991; 20:565-573.
Lewis J. Hiccups: Causes and cures. J Clin Gastro 1985; 7:539-552.
Rousseau, P. Hiccups. Southern Med J 1995;2:175-181.
Bondi, N, Bettelli, A. Treatment of hiccup by acupuncture in patients under anesthesia and in conscious patients. Minerva Med 1981; 72:2231-2234.
Treatment of intractable hiccup with baclofen: Results of a double-blind, randomized, controlled, cross-over study. A J Gastro 1992;87:1789-91.
Physicians Desk Reference, 2002

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #81 Hiccups. Farmer, C. January 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Creation Date: 1/2003
Format: Handouts
Purpose: Instructional Aid, Self-Study Guide, Teaching
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