eMedicine Specialties > Emergency Medicine > Gastrointestinal
Hiccups: Treatment & Medication
Updated: Sep 29, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
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
Other CNS depressants, anticholinergics, or anticonvulsants; antihypertensives may cause additive effect; coadministration with epinephrine may cause hypotension
Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease; circulatory collapse; CNS depression; pheochromocytoma
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.
Adult
10-20 mg PO tid/qid for 7 d
Pediatric
1-2 mg/kg PO tid/qid for 7 d
May antagonize effects of metoclopramide; opiate analgesics may increase metoclopramide toxicity in CNS
Documented hypersensitivity; pheochromocytoma; GI hemorrhage; obstruction or perforation of bowels; seizure disorders
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.
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
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
Documented hypersensitivity; sinoatrial block, sinus bradycardia, second-degree and third-degree AV block, or Adams-Stokes syndrome (because of effect on ventricular automaticity)
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.
Adult
10-15 mg/kg/d PO in 1-3 divided doses
Pediatric
Administer as in adults
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
Documented hypersensitivity; hepatic disease/dysfunction
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.
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
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)
Documented hypersensitivity; history of bone marrow depression; administration of MAOIs within last 14 d
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.
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
Ketamine increases CNS effects of narcotics, barbiturates, and hydroxyzine; thyroid hormones and muscle relaxants increase toxicity of ketamine
Documented hypersensitivity; angina; thyrotoxicosis; aneurysms; hypertension; congestive heart failure
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.
Adult
1 mg/kg IV loading dose followed by an infusion of 2 mg/min IV
Pediatric
Not established
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
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
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.
Adult
100 mg PO bid prn, 60 mg IM q12h prn
Pediatric
Not established
None reported
Documented hypersensitivity; GI obstruction; glaucoma; myasthenia gravis; cardiospasm
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).
Adult
10 mg PO bid/qid
Pediatric
Not established
Opiate analgesics, benzodiazepines, alcohol, tricyclic antidepressants, guanabenz, MAOIs, clindamycin, and hypertensive agents may increase baclofen effects
Documented hypersensitivity
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.
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
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
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.
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)
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
Documented hypersensitivity; narrow angle glaucoma; bone marrow suppression; severe cardiac or liver disease; severe hypotension; subcortical brain damage
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.
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
May increase toxicity of warfarin, CNS depressants, alcohol, and furosemide
Documented hypersensitivity; severe cardiac disease; hepatic or renal impairment; gastritis or ulcers
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.
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
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
Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS
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.
Adult
25 mg IM q6h
Pediatric
3 mg/kg/d PO/SC
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
Documented hypersensitivity; angle-closure glaucoma; cardiac arrhythmias
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.
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
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
Documented hypersensitivity; glaucoma; Tourette syndrome; motor tics; patients with agitation, tension, and anxiety
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
More on Hiccups |
| Overview: Hiccups |
| Differential Diagnoses & Workup: Hiccups |
 Treatment & Medication: Hiccups |
| Follow-up: Hiccups |
| References |
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