Fast Fact and Concept #81: Hiccups

Title: Fast Fact and Concept #81: Hiccups

Author(s): Chad Farmer, MD

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 lasting longer than 48 hours they are termed persistent; if longer than one month, intractable. Etiologies range from stress/excitement to cancer, myocardial infarction, gastric distension, liver disease, uremia, IV steroids, CNS lesions and idiopathic. Irritation of the vagus nerve or diaphragm are common pathophysiologic mechanisms.

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.

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.

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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.

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Creation Date: 1/2003

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice

Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery

Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Gastrointestinal, Neurologic

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).