Hiccups Bout: <48 hours of hiccups

Persistent hiccups: 48 hours – 1 month

Intractable Hiccups: >1 month

Why is this important?  You should workup PERSISTENT AND INTRACTABLE hiccups.

  • CNS: stroke, mass, infection, increased ICP

  • Diaphragm Irritation: Pneuomonia, cholecystitis, pericarditis, Myocardial Infarction

  • Stomach wall irritation: ileus, fullness, ulcer, obstruction

  • Phrenic nerve, Vagus Nerve, Recurrent Laryngeal Irritation: Infection, mass, trauma (recent surgery), etc.

  • Metabolic/Electrolyte abnormality: Uremia, etc

  • Toxins/Drugs: alcohol, etc

  • Remember, can possibly an angina equivalent.

  • Psychogenic

  • Other Infectious Etiologies (Ebola)


History, Physical Exam, Treatment should center around these causes.


History: Alcohol use, medication changes, recent surgeries


  • HEENT exam including otoscope and throat exam: r/o infection, mass, lymphadenopathy, foreign body etc

  • Neuro exam

  • Abdominal exam

  • Lung exam


EKG, CBC, electrolytes, blood urea nitrogen (BUN), creatinine, calcium, liver function tests, and amylase/lipase, ecg, consider cxr.

Treatment:  Most therapies are based on case reports or small studies and are focused on treating the underlying cause.


  • Physical Maneuvers (try first): Breatholding, Valsalva (against syringe), ice water gargle, pressing eyeballs, knee to chest to compress chest.

  • Pharmacological therapy

o   These aim to resolve the physiological causes of hiccups

  • Chlorpromazine 25 mg three times daily PO/IV (if given IV give with bolus).

  • Only FDA approved drug based on case series

  • Phenothiazine; dopamine antagonist

  • Metoclopramide 10 mg three or four times daily orally

  • Dopamine antagonist and gastric motility agent

  • Baclofen 5-20mg three times daily orally

  • Skeletal muscle relaxant

  • Haldol 5-10mg PO or IV

Included is a table of pharmacologic treatments based on possible cause:

Gastric Distenstion GERD Diaphragmatic Irritation Central Acting Agents Dopamine Antagonist GABA Agonist Simethicone 25mg (antiflatulant) Metoclopramide 10mg QDS PO (prokinetic) Haloperidol 1.5-3mg qhs Chlorpromazine 10-25mg PO or IV Baclofen Metoclopramide 10mg (prokinetic) PO H2 blocker or PPI Baclofen 5-20mg three times daily orally Haloperidol 5-10mg PO or IV Sodium valproate 200-500mg PO Nifedipine 10-20mg three times daily orally Metoclopramide Midazolam 10-60mg/24h (really for terminal hiccups)! Sodium valproate, aim for 15mg/kg/24h in divided doses

Others: Carvedilol, Gabapentin, Lidocaine oral soln, Olanzapine, amitryptiline, Cisapride, marijuana


*If intractable hiccups remain resistant to non-pharmacological techniques, the strongest evidence to date supports the use of chlorpromazine 25 to 50 mg administered intravenously, with a second dose within 2 to 4 hours intravenously or intramuscularly



Palliative Care Medicine Information Service

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