eMedicine Specialties > Emergency Medicine > Gastrointestinal

Hiccups

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Director, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia, Australia.

Updated: Sep 29, 2009

Introduction

Background

The term "hiccup" derives from the sound of the event. "Hiccough" erroneously implies an association with respiratory reflexes. The medical term, singultus, is thought to have originated from the Latin, singult, which translates roughly as "the act of catching one's breath while sobbing."

Brief episodes of hiccups, which often induce annoyance in patients and merriment in observers, are a common part of life. Prolonged attacks are a more serious phenomenon and often a diagnostic dilemma. These attacks have been associated with significant morbidity and even death.

A hiccup bout is any episode lasting more than a few minutes. If hiccups last longer than 48 hours, they are considered persistent or protracted. Hiccups lasting longer than one month are termed intractable. The longest recorded attack is 6 decades.

Pathophysiology

Hiccups appear to serve no purpose in humans or other mammals. Often, only one hemidiaphragm is affected. The left hemidiaphragm is affected in 80% of cases, although bilateral involvement may occur.

Hiccups occur 4-60 times per minute until a certain number has been delivered. Typically, this is fewer than 4 or more than 30. The frequency is relatively constant for a given individual and varies inversely with arterial PCO₂. Loudness and rapidity of hiccups are unrelated. Hiccups are more common in the evening and may continue for a few waking hours. Hiccups occur most frequently during the first half of the menstrual cycle, especially in the few days before menstruation, and decrease markedly during pregnancy.

The exact cause remains a mystery despite centuries of contemplation. Hippocrates and Celsus associated hiccups with liver inflammation and other conditions. Galen believed hiccups were due to violent emotions arousing the stomach.

In 1833, Shortt first recognized an association between hiccups and phrenic nerve irritation.

The hiccup reflex, originally proposed by Bailey in 1943, consists of the following:

• Afferent limb - Phrenic and vagus nerves and sympathetic chain arising from T6-12
• Hiccup center - Nonspecific location between C3 and C5
• Connections to the respiratory center, phrenic nerve nuclei, medullary reticular formation, and hypothalamus
• Efferents
  
  
  • Phrenic nerve (C3-5)
  • Anterior scalene muscles (C5-7)
  • External intercostals (T1-11)
  • Glottis (recurrent laryngeal component of vagus)
  • Inhibitory autonomic processes
  • Decreasing esophageal contraction tone
  • Lower esophageal sphincter tone

Sex

Overall incidence of hiccups is equal between males and females; however, protracted and intractable hiccups occur more frequently in men (82% of cases).

Age

Hiccups occur at any age and in utero. Preterm infants spend up to 2.5% of their time hiccupping. Although hiccups occur less frequently with advancing age, intractable hiccups are more common in adult life. Females develop hiccups more frequently during early adulthood than males of the same age.

Clinical

History

Medical training is not required to diagnose hiccups. Brief episodes that self-terminate or that respond to simple maneuvers need no investigation or follow-up care.

In contrast, persistent and intractable hiccups frequently are associated with an underlying pathological process and may induce significant morbidity. The focus of the history, examination, and investigation is to identify these causes and effects.

• Hiccups that abate with sleep and temporally relate to stressful circumstances commonly are psychogenic in origin.
• Arrhythmia-induced syncope has been reported as both the cause and the effect of hiccups.
• Gastroesophageal reflux may cause or result from hiccups.
• Weight loss, insomnia, and emotional distress may complicate prolonged episodes.
• A full systemic inquiry, surgical history, and comprehensive drug history may reveal one of the many causes (see Causes).
• Alcoholism and acute alcohol ingestion may contribute to the development of hiccups.

Physical

A full physical examination is necessary. Considering the wide range of differentials, a complete and focused physical examination may yield evidence of the following:

• Head - Including ears, eyes, entire scalp
  • Foreign body or aberrant hair adjacent to tympanic membrane
  • Glaucoma
• Mouth -Pharyngitis
• Neck
  • Inflammation (including laryngitis)
  • Mass lesions
  • Goiter
  • Voice abnormalities (recurrent laryngeal nerve)
• Chest
  • Tumors
  • Pneumonia
  • Asthma
• Cardiovascular
  • Arrhythmias
  • Myocardial infarction (MI)
  • Pericarditis
  • Unequal pulses -Thoracic aortic aneurysm
• Abdominal
  • Gastric atony - Succussion splash
  • Organomegaly
  • Subphrenic abscess
  • Cholecystitis
  • Appendicitis
  • Abdominal aortic aneurysm (AAA)
  • Pancreatitis
  • Peritonitis
• Rectal - Mass lesions
• Neurologic
  • Focal lesions
  • Disordered higher mental function
  • Indications of multiple sclerosis
• Neck stiffness - Possible indication of tumors or infection

Causes

Typical causes include gastric distention (ie, food, alcohol, air), sudden changes in ambient or gastric temperature, and use of alcohol and/or tobacco in excess. Psychogenic causes (ie, excitement, stress) also may elicit hiccups.

Persistent or intractable episodes are more likely to result from serious pathophysiological processes affecting a component of the hiccup reflex mechanism. More than 100 causes have been described; however, in many cases, the cause remains idiopathic. These may be classified as follows:

• Eighty-two percent of persistent or intractable episodes occur in men. An organic cause can be identified in 93% of men and in 8% of women, resulting in an overall organic incidence of 80%. The remaining 20% are considered psychogenic in origin.
  • Hysteria
  • Shock
  • Fear
  • Personality disorders
  • Conversion disorders
  • Malingering
• Central nervous system
  • Structural¹ - Congenital malformations, malignancies, multiple sclerosis
  • Vascular lesions
  • Infection
  • Trauma
• Diaphragmatic irritation
  • MI
  • Pericarditis
  • Hiatal hernia
  • Subphrenic abscess
• Vagus nerve irritation
  • Meningeal branches - Meningitis, glaucoma
  • Auricular branches - Foreign body, hairs
  • Pharyngeal branches - Pharyngitis
  • Recurrent laryngeal nerve - Mass lesions in neck, goiter, laryngitis²
  • Thoracic branches - Infection, tumors, esophagitis (ie, reflux), MI, asthma, trauma, thoracic aortic aneurysm
  • Abdominal branches - Tumors, gastric distension, peptic ulcer, AAA, infection, organ enlargement, inflammation (eg, appendicitis, cholecystitis, inflammatory bowel disease)
• Procedure/anesthesia related^3,4
  • Hyperextension of neck - Stretching phrenic nerve roots
  • Manipulation of diaphragm or stomach
  • Laparotomy
  • Thoracotomy
  • Craniotomy
• Metabolic
  • Hyponatremia
  • Hypokalemia
  • Hypocalcemia
  • Hyperglycemia
  • Uremia
  • Hypocarbia
  • Fever
• Drugs
  • Benzodiazepines
  • Short-acting barbiturates
  • Dexamethasone
  • Alpha methyldopa

Differential Diagnoses

Other Problems to Be Considered

Acute peritonitis
Diaphragmatic hernias
Postsurgical - Cranial, thoracic, abdominal

Workup

Laboratory Studies

• A wide variety of laboratory abnormalities may contribute to hiccups, depending on the findings from the history and physical examination. Direct laboratory testing toward suspected abnormalities.
• Electrolytes
• Hyponatremia can be the cause (including Addison disease) and effect (drinking water as a cure).
• Other causes include hypokalemia, hypocalcemia, and hyperglycemia.
• Renal function tests - Uremia
• Liver function tests - Hepatitis
• Amylase and lipase measurement - Pancreatitis
• White blood cell count
• Certain infectious diseases may cause a patient to hiccup. Appropriate testing may include the following:
• Urine
• Sputum
• Cerebrospinal fluid (CSF)

Imaging Studies

• Chest radiography
  • Tumors
  • Infection
  • Thoracic aorta
• Fluoroscopy of diaphragmatic movement
  • Confirm diagnosis if malingering suspected.
  • Determine if unilateral or bilateral before invasive therapy.
• CT scan - Head, thorax, abdomen
  • Tumors
  • Infection
  • Structural lesions
• Magnetic resonance imaging
  • Multiple sclerosis
  • Vascular relations to vagus and phrenic nerves

Other Tests

• Electrocardiography
  • MI
  • Pericarditis
  • Arrhythmias

Procedures

• Prior to invasive therapy, perform nerve conduction studies to confirm the diagnosis and to confirm the presence of unilateral or bilateral involvement.
• Endoscopy, bronchoscopy, or GI radiography may be indicated.
• Prior to corrective surgery, obtain an esophageal acid perfusion test to determine if gastroesophageal reflux is a causative factor.

Treatment

Prehospital Care

Administer supportive care as indicated by the causative pathology (eg, oxygen for the patient whose hiccups may be secondary to pneumonia).

Emergency Department Care

Generations of physicians have yet to discover a definitive cure for hiccups. A statement from the Mayo Clinic expressed the situation perfectly in 1932, "The amount of knowledge on any subject such as this can be considered as being in inverse proportion to the number of different treatments suggested and tried for it."

Direct therapy at the cause of the hiccups, if identified, and then to the hiccups themselves, if needed. Treatments can be divided into the categories of pharmacologic, nonpharmacologic, and other. Elements of nonpharmacologic treatments are as follows:

• Many traditional remedies used in an ED have a sound physiological basis affecting components of the hiccup reflex.
  • Stimulation of nasopharynx - Forcible traction on the tongue, swallowing granulated sugar, gargling with water, sipping ice water, drinking from the far side of a glass, biting on a lemon, inhaling noxious agents (eg, ammonia)
  • C3-5 dermatome stimulation - Tapping or rubbing back of the neck, coolant sprays, acupuncture
  • Direct pharyngeal stimulation - Nasal or oral catheter (90% effective)
  • Direct uvular stimulation - Spoon or cotton-tip applicator
  • Removal of gastric contents - Emetics, nasogastric tube
• Vagal stimulation (Only one technique at a time is recommended.)
  • Iced gastric lavage
  • Valsalva
  • Carotid sinus massage (only by experienced personnel after exclusion of contraindications)
  • Digital ocular globe pressure (only by experienced personnel after exclusion of contraindications)
  • Digital rectal massage
• Interference with normal respiratory function - Breath holding, hyperventilation, gasping (ie, fright), breathing into a paper bag (increases partial pressure of carbon dioxide), pulling knees up to chest and leaning forward, continuous positive airway pressure, rebreathing 5% carbon dioxide
• Mental distraction - For example, ask the patient to "think of a loved one remembering you." An inventive naval doctor achieved success by offering $10 if the patient could continue to hiccup immediately.
• Other
  • Behavioral conditioning (including other members of the family unit)
  • Hypnosis
  • Acupuncture (including near-infrared irradiation of acupoints)^5,6,7
  • Phrenic nerve or diaphragmatic pacing: Incidental cure during cardioversion has been reported.
  • Phrenic nerve block surgery: Surgical interruption of the phrenic nerve has been advocated for intractable cases that are unresponsive to other treatment. This final and most drastic approach may be associated with considerable morbidity and is not universally successful. Microvascular decompression of the vagus nerve has been described as a successful procedure.^8,9
  • Prayer: The most novel cure for one patient was to pray to the Catholic patron saint of lost causes, St. Jude. After 8 years and more than 60,000 suggested treatments, his prayer to St. Jude was answered.

Consultations

Consultation rarely is necessary unless the etiology of hiccups requires a specialist.

Medication

Various agents have been reported to cure hiccups. Chlorpromazine is the most studied and appears to be the drug of choice. Increments of 25-50 mg IV/IM are effective in 80% of cases. To avoid or minimize hypotension from the agent, preloading the patient with 500-1000 mL of IV fluid is advised.

Another major tranquilizer, haloperidol, is effective in doses of 2-5 mg. Metoclopramide has been used successfully in a dose of 10 mg every 8 hours.

Several anticonvulsant agents have been used to treat intractable hiccups. Phenytoin, valproic acid, and carbamazepine have been effective when used in typical anticonvulsant doses. Gabapentin has been shown to be effective where CNS lesions are present and in some other etiological groups.^10,11

Of the anesthetic agents, ketamine has been the most successful at a dose of 0.4 mg/kg (one fifth of the usual anesthetic dose). Baclofen,¹² a centrally acting muscle relaxant, administered at 10 mg PO 4 times a day, particularly is useful in patients for whom other agents are contraindicated (eg, those with renal impairment). Intravenous lidocaine in a loading dose of 1 mg/kg, followed by an infusion of 2 mg/min, has cured patients after other agents were unsuccessful.

Other agents reported to be beneficial include muscle relaxants, sedatives, analgesics (eg, orphenadrine, amitriptyline, chloral hydrate, morphine), stimulants (eg, ephedrine, methylphenidate, amphetamine, nikethamide), and a miscellaneous group including edrophonium, dexamethasone, amantadine, and nifedipine. Benzodiazepines have been shown to exacerbate or precipitate hiccups and should be avoided.

Antiemetics

These agents are effective in treating hiccups.

Chlorpromazine (Thorazine)

DOC; antidopaminergic drug; blocks postsynaptic mesolimbic dopamine receptors; has anticholinergic effect; can depress the reticular activating system (possibly all are responsible for relieving nausea and vomiting); blocks alpha-adrenergic receptors; depresses release of hypophyseal and hypothalamic hormones.

Dosing

Adult

25-50 mg PO tid/qid; slow IV infusion with patient lying flat when symptoms persist; 25-50 mg in addition to 500-1000 mL of saline (monitor blood pressure); 25-50 mg IM if symptoms persist for 2-3 d

Pediatric

Not established

Interactions

Other CNS depressants, anticholinergics, or anticonvulsants; antihypertensives may cause additive effect; coadministration with epinephrine may cause hypotension

Contraindications

Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease; circulatory collapse; CNS depression; pheochromocytoma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

May cause pseudoparkinsonism; akathisia is a common extrapyramidal reaction in elderly persons; lowers seizure threshold and increases risk of seizures in patients with history of seizures

Metoclopramide (Reglan)

Blocks dopamine receptors in the chemoreceptor trigger zone of CNS.

Dosing

Adult

10-20 mg PO tid/qid for 7 d

Pediatric

1-2 mg/kg PO tid/qid for 7 d

Interactions

May antagonize effects of metoclopramide; opiate analgesics may increase metoclopramide toxicity in CNS

Contraindications

Documented hypersensitivity; pheochromocytoma; GI hemorrhage; obstruction or perforation of bowels; seizure disorders

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in history of mental illness and Parkinson disease

Anticonvulsants/antiarrhythmic

These agents are used for severe muscle spasms.

Phenytoin (Dilantin)

Inhibits spread of motor activity by acting in motor cortex.

Dosing

Adult

15-20 mg/kg IV loading dose followed by a maintenance dose of 2-3 mg/kg PO bid; individualize further doses per blood levels and tolerability if chronic dosing required

Pediatric

15-20 mg/kg PO/IV loading dose once or in divided doses, followed by an initial dose of 5 mg/kg/d PO/IV divided bid/tid and a maintenance dose of 4-8 mg/kg PO/IV divided bid/tid

Interactions

Amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, phenylbutazone, succinimides, sulfonamides, omeprazole, phenacemide, disulfiram, ethanol (acute ingestion), trimethoprim, and valproic acid may increase phenytoin toxicity
Phenytoin effects may decrease when taken concurrently with barbiturates, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, carbamazepine, theophylline, and sucralfate
May decrease effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, quinidine, theophylline, methadone, metyrapone, mexiletine, oral contraceptives, valproic acid

Contraindications

Documented hypersensitivity; sinoatrial block, sinus bradycardia, second-degree and third-degree AV block, or Adams-Stokes syndrome (because of effect on ventricular automaticity)

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Perform blood counts and urinalyses at the beginning of therapy and at monthly intervals for several months thereafter to monitor for blood dyscrasias; discontinue use if rash appears; if rash is exfoliative, bullous, or purpuric, do not resume use; death from cardiac arrest after too rapid IV administrations (sometimes preceded by marked QRS widening); caution with acute intermittent porphyria; caution with diabetes (may raise blood sugar levels); discontinue drug if hepatic dysfunction occurs

Valproic acid (Depakote, Depakene)

Although mechanism of action is not established, activity may be related to increased brain levels of gamma-aminobutyric acid (GABA), or enhanced GABA action. Valproate may also potentiate postsynaptic GABA responses, affect potassium channel, or have a direct membrane-stabilizing effect.

Dosing

Adult

10-15 mg/kg/d PO in 1-3 divided doses

Pediatric

Administer as in adults

Interactions

Coadministration with cimetidine, salicylates, felbamate, and erythromycin may increase toxicity; rifampin may significantly reduce valproate levels; in pediatric patients, protein binding and metabolism of valproate decrease when taken concomitantly with salicylates; coadministration with carbamazepine may result in variable changes of carbamazepine concentrations with possible loss of seizure control; valproate may increase diazepam and ethosuximide toxicity (monitor closely); valproate may increase phenobarbital and phenytoin levels while either one may decrease valproate levels; valproate may displace warfarin from protein-binding sites (monitor coagulation tests); may increase zidovudine levels in HIV seropositive patients

Contraindications

Documented hypersensitivity; hepatic disease/dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Thrombocytopenia and abnormal coagulation parameters have occurred; the risk of thrombocytopenia increases significantly at total trough valproate plasma concentrations >110 mcg/mL in females and 135 mcg/mL in males; at periodic intervals and prior to surgery, determine platelet counts and bleeding time before initiating therapy; reduce dose or discontinue therapy if hemorrhage, bruising, or a hemostasis/coagulation disorder occur; hyperammonemia may occur, resulting in hepatotoxicity; monitor patients closely for appearance of malaise, weakness, facial edema, anorexia, jaundice, and vomiting; may cause drowsiness

Carbamazepine (Tegretol)

May block post-tetanic potentiation by reducing summation of temporal stimulation.

Dosing

Adult

200 mg PO bid (100 mg PO qid if susp)

Pediatric

<6 years: 10-20 mg/kg/d PO bid/tid (qid with susp)
6-12 years: 100 mg PO bid (50 mg qid of susp)
>12 years: Administer as in adults, not to exceed 1000 mg/d in children aged 12-15 years or 1200 mg/d in >15 years

Interactions

Serum levels may increase significantly within 30 d of danazol coadministration (avoid whenever possible); do not coadminister with MAOIs; cimetidine may increase toxicity especially if taken in first 4 wk of therapy; carbamazepine may decrease primidone and phenobarbital levels (their coadministration may increase carbamazepine levels)

Contraindications

Documented hypersensitivity; history of bone marrow depression; administration of MAOIs within last 14 d

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use to relief minor aches or pains; caution with increased intraocular pressure; obtain CBCs and serum iron baseline prior to treatment, during first 2 months, and yearly or every other year thereafter; can cause drowsiness, dizziness, and blurred vision; caution while driving or performing other tasks that require alertness

Anesthetics

Agents with effects in muscle contractions appear to be effective.

Ketamine (Ketalar)

Acts on the cortex and limbic system, decreasing muscle spasms.

Dosing

Adult

0.4 mg/kg (one fifth of the usual anesthetic dose) IV; supplemental dose of 1/3 to 1/2 initial dose may be given for maintenance

Pediatric

Not established

Interactions

Ketamine increases CNS effects of narcotics, barbiturates, and hydroxyzine; thyroid hormones and muscle relaxants increase toxicity of ketamine

Contraindications

Documented hypersensitivity; angina; thyrotoxicosis; aneurysms; hypertension; congestive heart failure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Resuscitative equipment should be immediately available during administration of medication

Lidocaine (Dilocaine, Xylocaine, Anestacon)

Inhibits depolarization of type C sensory neurons by blocking sodium channels.

Dosing

Adult

1 mg/kg IV loading dose followed by an infusion of 2 mg/min IV

Pediatric

Not established

Interactions

Coadministration with cimetidine or beta-blockers increases toxicity of lidocaine; coadministration with procainamide and tocainide may result in additive cardiodepressant action; may increase effects of succinylcholine

Contraindications

Documented hypersensitivity to amide-type local anesthetics; avoid in Adams-Stokes syndrome and Wolff-Parkinson-White syndrome; avoid in severe sinoatrial, atrioventricular (AV), or intraventricular block, if artificial pacemaker not in place

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Use a solution without preservatives; caution in heart failure, hepatic disease, hypoxia, hypovolemia or shock, respiratory depression, and bradycardia; may increase risk of adverse CNS and cardiac effects in elderly persons; high plasma concentrations can cause seizures, heart block, and AV conduction abnormalities

Muscle relaxants

These agents may reduce muscle contractions.

Orphenadrine (Norflex)

While exact mode of action not well understood, has shown clinical effectiveness in treating hiccups.

Dosing

Adult

100 mg PO bid prn, 60 mg IM q12h prn

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; GI obstruction; glaucoma; myasthenia gravis; cardiospasm

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiac arrhythmias and congestive heart failure

Baclofen (Lioresal)

May induce the hyperpolarization of afferent terminals and inhibit both monosynaptic and polysynaptic reflexes at the spinal level. Useful in patients for whom other agents are contraindicated (eg, those with renal impairment).

Dosing

Adult

10 mg PO bid/qid

Pediatric

Not established

Interactions

Opiate analgesics, benzodiazepines, alcohol, tricyclic antidepressants, guanabenz, MAOIs, clindamycin, and hypertensive agents may increase baclofen effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with history of autonomic dysreflexia and when spasticity is utilized to obtain increased function; autonomic dysreflexia can result from withdrawal of this medication

Sedatives

Agents with effects in spastic muscles have shown effectiveness.

Morphine (Duramorph, Astramorph)

DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.

Dosing

Adult

0.01-0.02 mg/kg IV q5-10min titrated to effect; 0.1-0.2 mg/kg IM q2-4h titrated to effect

Pediatric

Administer as in adults

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Haloperidol (Haldol)

Useful in treatment of irregular spasmodic movements of muscles.

Dosing

Adult

2-5 mg PO q4-8h

Pediatric

0.05-0.15 mg/kg/d PO in 2-3 divided doses (not to exceed 0.15 mg/kg/d)

Interactions

May increase tricyclic antidepressant serum concentrations and hypotensive action of antihypertensive agents; phenobarbital or carbamazepine may decrease effects of haloperidol; haloperidol coadministration with anticholinergics may increase intraocular pressure; encephalopathylike syndrome associated with concurrent administration of lithium and haloperidol

Contraindications

Documented hypersensitivity; narrow angle glaucoma; bone marrow suppression; severe cardiac or liver disease; severe hypotension; subcortical brain damage

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Severe neurotoxicity manifesting as rigidity or inability to walk or talk may occur in patients with thyrotoxicosis also receiving antipsychotics; if IV/IM, watch for hypotension; caution in diagnosed CNS depression or cardiac disease; if history of seizures, benefits must outweigh risks; significant increase in body temperature may indicate intolerance to antipsychotics (discontinue it occurs)

Chloral hydrate (Aquachloral, Supprettes)

Has central nervous system depressant effects. Mechanism unknown.

Dosing

Adult

500-1000 mg PO/PR; not to exceed 2 g/d

Pediatric

50-75 mg/kg PO/PR; not to exceed 2 g divided bid

Interactions

May increase toxicity of warfarin, CNS depressants, alcohol, and furosemide

Contraindications

Documented hypersensitivity; severe cardiac disease; hepatic or renal impairment; gastritis or ulcers

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperbilirubinemia and porphyria

Tricyclic antidepressants

A complex group of drugs that have central and peripheral anticholinergic effects as well as sedative effects. They block the active reuptake of norepinephrine and serotonin.

Amitriptyline (Elavil)

Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS. May also have analgesic effects.

Dosing

Adult

10-40 mg PO qhs (50-150 mg may be necessary in some individuals)

Pediatric

Children: 0.1 mg/kg PO hs; increase, as tolerated, over 2-3 wk to 0.5-2 mg/d hs
Adolescents: 25-50 mg/d PO initially; increase gradually to 100 mg/d in divided doses

Interactions

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase amitriptyline levels; amitriptyline inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Contraindications

Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in elderly persons

Stimulants

Mechanisms of action in the treatment of hiccups are not well understood.

Ephedrine (Pretz-D)

Stimulates release of epinephrine stores, producing alpha-adrenergic and beta-adrenergic effects.

Dosing

Adult

25 mg IM q6h

Pediatric

3 mg/kg/d PO/SC

Interactions

Theophylline, atropine, or MAOIs may increase toxicity; alpha-blockers and beta-blockers decrease vasopressor effects of ephedrine; cardiac glycosides and general anesthetics increase cardiac stimulation of ephedrine

Contraindications

Documented hypersensitivity; angle-closure glaucoma; cardiac arrhythmias

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in elderly persons and in those with diabetes mellitus, hyperthyroidism, hypertension, cardiovascular disease, prostatic hypertrophy, or cerebrovascular insufficiency

Methylphenidate (Ritalin)

Stimulates cerebral cortex and subcortical structures.

Dosing

Adult

5 mg PO qam or divided bid; not to exceed 60 mg/d

Pediatric

5 mg PO qam; optimal dose 0.3-0.7 mg/kg/d divided bid/tid

Interactions

Reduces effects of guanethidine and bretylium; toxicity of phenytoin, tricyclic antidepressants, warfarin, primidone, and phenobarbital may increase when administered concurrently with methylphenidate; MAOIs increase toxicity of methylphenidate

Contraindications

Documented hypersensitivity; glaucoma; Tourette syndrome; motor tics; patients with agitation, tension, and anxiety

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in dementia, seizures, and hypertension

Follow-up

Complications

• Arrhythmias
• Gastroesophageal reflux
• In prolonged cases, weight loss and sleep disturbance may be noted.

Prognosis

• Hiccups generally are self-limited, and the prognosis is excellent. The prognosis of protracted hiccups is related to that of the underlying etiology.

Miscellaneous

Medicolegal Pitfalls

• Protracted hiccups often are associated with underlying organic disease and often induce social and emotional distress.
• Therapy must address causative and complicating factors of protracted hiccups.

Special Concerns

• Gastroesophageal reflux is associated closely with hiccups but may be either cause or effect. Perform acid perfusion studies confirming the inducibility of hiccups before proceeding with antireflux surgery to cure hiccups.
• The final and most drastic treatment is phrenic nerve ablation. Fluoroscopic examination may reveal unilateral involvement allowing directed therapy. Temporary blockade is advisable initially. Bilateral phrenic nerve interruption may lead to significant respiratory complications and may not always cure hiccups, as other respiratory muscles are involved. Explore all other treatments prior to this step.
• Patients rarely present to the ED after cessation of a brief episode of hiccups. If this occurs, first consider another reason (eg, depression) for the presentation.

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Keywords

hiccups, hiccoughs, singultus, gastric distention, alcohol, tobacco, excitement, stress, phrenic nerve irritation

Contributor Information and Disclosures

Author

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Director, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia, Australia.
Disclosure: Nothing to disclose.

Medical Editor

Robin R Hemphill, MD, MPH, Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University
Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Brief episodes of hiccups are typically of little impact and often merely a source of amusement. In contrast, persistent and intractable can be of enormous impact, impairing all aspects of daily life. My thanks to those who have shared their stories including success or otherwise.

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