Treatment for hiccups

In general, most bouts of hiccups will disappear on their own within a few minutes or hours without any cause for concern. To get rid of hiccups you can try one of the physical manoeuvres mentioned below.  

When should I seek medical attention for my hiccups?

If hiccups last for more than two days (48 hours), affect eating, sleep patterns or result in the reflux of food and/or vomiting, then medical attention should be sought.

Bear in mind, hiccups are very rarely considered a medical emergency.

What kind of doctor will treat my hiccups?

Due to the fact that hiccups are not generally considered a medical emergency, a general practitioner or paediatrician for children is usually the first line of consultation sought.

Other specialists that may be a part of a medical team treating intractable hiccups include:

• Otolaryngologists – Also known as a, ear, nose and throat specialists
• Gastroenterologists – Medical experts who specialise in digestive tract issues and disorders.
• Neurologists – Specialists in the function of the nervous system and brain
• Pulmonologists – Doctors who specialise in treating lung conditions

The treatment protocol for hiccups 

The treatment for hiccup bouts tends to focus on home remedies as there are a number of different methods that have shown success when stopping the occurrence of hiccups. However, the treatment of chronic hiccups is slightly more complicated as the majority of the approaches to treating chronic hiccups are based more on observational studies and case reports, and there is a lack of findings based on large, randomised controlled trials¹⁰. 

A systemic review¹¹ conducted in 2013 found that due to a lack of randomised trials that evaluate the pharmacological treatment of chronic hiccups, there is insufficient evidence available to inform health experts on the non-pharmacological and pharmacological treatment options for persistent or intractable hiccups.

It is generally accepted that the treatment for chronic hiccups should be focused on treating the cause, should one be identified. However, persistent hiccups are commonly idiopathic, meaning they arise spontaneously and have an unknown cause.

If a doctor is unable to find the cause of hiccups, then the first-line of treatment is often physical manoeuvres coupled with empirical therapy. Empirical therapy refers to treatment that is based on clinically educated assumptions as a result of the cause being unknown. The physical manoeuvres performed are associated with a low risk of any potential complications arising. Only if these manoeuvres fail, then pharmacological therapy will be used.

Physical manoeuvres (i.e. non-pharmacological therapy) that may be performed to eliminate hiccups include the following:

(Please note that these techniques are based on isolated case reports and the efficacy of these has not yet been scientifically confirmed)

• Interrupting normal respiratory functioning – This refers to what is known as the Valsalva manoeuvre or holding one’s breath. To perform the Valsalva manoeuvre, the patient will be required to attempt to exhale whilst keeping the nose and mouth closed (i.e. this is an exhalation against an airway that is closed). This will be attempted for 10 to 15 seconds and feels as though one is inflating a balloon. This exercise will be repeated if hiccups persist.
• Stimulating the nasopharynx (i.e. the upper area of the throat that lies behind the nose) or uvula (i.e. the projection of soft tissue that hangs from the back of the throat). This can be done by swallowing a teaspoon of sugar, sipping on cold water or gargling with water.
• Increasing vagal stimulation – Stimulating the vagus nerve, which is responsible for the coordination of breathing and swallowing, can be performed via digital rectal message which involves massaging the anus in a slow and circular motion. The reason for the success of this technique, which may seem rather absurd, is due to the fact that the rectum is supplied with a large number of nerves (the vagus nerve is connected to this network of nerves) and massaging this area may lead to an increase in vagal stimulation as a result.
• Counteracting diaphragm irritation – Irritation of nerves in the diaphragm may result in spasms which consequently lead to hiccups. Counteracting this irritation through pulling the knees up to the chest and leaning forward to compress and apply pressure to the chest may lessen the severity of hiccups or aid in ridding one of them.

Pharmacological therapy for chronic hiccups

Should the aforementioned physical manoeuvres fail, there are a number of different classes of drugs that can be prescribed in the treatment of chronic hiccups. Due to the absence of research and data to compare the efficacy of the various drug treatments for chronic hiccups, experts may suggest that chlorpromazine should be the first line of treatment as this has been a commonly used drug in the treatment of the condition and generally regarded as a well-tolerated drug that offers successful results.

Should chronic hiccups subside as a result of treatment, then the drugs can usually be stopped a day or so after cessation is achieved. The majority of drug treatments are prescribed for use over a period of seven to 10 days. If hiccups persist, then a doctor is likely to consider a different treatment option which may be pharmacological, non-pharmacological or a combination of both.

The following information describes some of the pharmacological drug treatments for persistent and intractable hiccups¹⁰:

Chlorpromazine (Thorazine) – An antipsychotic drug

• This drug, which is a derivative of phenothiazine, is the most commonly prescribed drug in the treatment of chronic hiccups and is the only medication that has been approved by the FDA (Food and Drug Administration) in the US for this purpose. Chlorpromazine, however, has some severe side effects, these include urinary retention, delirium, hypotension (low blood pressure) and glaucoma (a group of diseases that cause damage to the optic nerve that results in loss of vision). However, these are only potential side effects and do not occur in all patients. The drug acts centrally through blocking dopamine receptors in the hypothalamus. Dopamine is a neurotransmitter that aids in the regulation of movement and emotions.

Metoclopramide (Reglan)

• This drug is a dopamine antagonist (i.e. blocks dopamine receptors), as well as gastric mobility agent (i.e. it helps empty the stomach of its contents). Metoclopramide is also known as a prokinetic agent, which is a type of drug that strengthens the lower oesophageal sphincter (LES), and allows for stomach contents to empty at a faster rate. This type of drug is used in the treatment of acid reflux and has also shown efficacy when treating chronic hiccups. Chronic use and high dosages may result in tardive dyskinesia (a neurological condition that causes involuntary movements of the jaw and face).

Baclofen

• This drug is a skeletal muscle relaxant and has shown success in the treatment of intractable hiccups. Baclofen may result in dizziness and drowsiness.

Chemotherapy-associated hiccups

• Dexamethasone, which is a treatment often given to combat the side effects of chemotherapy such as nausea and vomiting, may cause hiccups in cancer patients, however, this same drug has shown effective results in terminating chronic hiccups in AIDS-related PML (progressive multifocal leukoencephalopathy). PML is a fatal and rare viral disease that involves inflammation of, or progressive damage to, the white matter of the brain.

Other drug options

• Anticonvulsants – Also known as anti-seizure drugs, some of which are used in the treatment of hiccups include:
  • Carbamazepine (Tegretol)
  • Valproic acid
  • Gabapentin (Neurontin)
  • Pregabalin (Lyrica)
• Antidepressants –
  • Amitriptyline (Elavil)
• Central nervous system (CNS) stimulants –
  • Methylphenidate (Ritalin)
• Antiarrhythmic drugs – These drugs are used to suppress abnormal heart rhythms and include:
  • Quinidine (sulfate/sulphate, gluconate)

CAM (complementary and alternative medicine) treatments

Should chronic hiccups persist and not respond to physical manoeuvres or drug therapy, then CAM treatment options may be attempted, such as acupuncture, which has been to improve chronic hiccups in a number of observational studies¹². Although the exact benefits associated with acupuncture are still uncertain, this form of alternative treatment is generally deemed a safe approach to treating chronic hiccups.

Hypnosis is another form of treatment that has shown some success in the treatment of intractable hiccups in some case studies¹³.

Surgery

There are some surgical approaches to treating stubborn cases of hiccups that do not respond to other treatments. These include:

• Phrenic nerve surgery – The phrenic nerve is the nerve that that controls the diaphragm. Phrenic nerve surgery entails the surgical crushing or blocking of this nerve through the use of a local anaesthetic. This treatment option is regarded as the last resort in attempting to terminate chronic hiccups.
• Other surgeries – There has been some success in the termination of hiccups through the installation of an implantable breathing pacemaker, also known as a phrenic nerve stimulator, which is a device responsible for controlling diaphragm movement through electronic stimulation of the phrenic nerve.
  
  The implantation of a vagus nerve stimulator (VNS) may also be beneficial in terminating hiccups, this procedure implants a device which operates by sending electric pulses to the brain through the vagal nerve.

Lifestyles Changes to prevent regular hiccups

Those who suffer from regular bouths of hiccups may consider making some lifestyle changes as follows:

• Make a point of eating slowly and limiting portions - hiccups are often caused by eating too fast or too much, which causes the stomach to swell and triggers hiccups. 
• Try an acid reflux diet - If hiccups are linked to acid reflux, and you're also suffering from heartburn, an acid reflux diet which entails avoiding fried, fatty and processed foods, alcohol and carbonated beverages and consuming lean white meat, plenty of green vegetables and non-acidic fruit.
• Actively reduce stress as far as possible - stress exacerbates digestive issues which can lead to hiccups. While easier said than done, taking active steps to reduce stress though regular exercise, breathing techniques or meditation can help to ease feelings of anxiety associated with stress and alleviate hiccups.

Treating Hiccups in Newborns

If a baby develops hiccups, a pacifier may help to relax the diaphragm. If this is not effective, try feeding breast or bottle feeding as this may help to stop hiccups.

Hiccups can also be prevented by:

• Feeding a baby when he / she is calm and in an upright position.
• Burping the baby throughout the feeding, changing positions often as this helps to eliminate the gas which can cause hiccups.
• Waiting at least 20 to 30 minutes before engaging the child in any physical activity like bouncing or swinging.

 

^References: 

^{10. NCBI. 2011. Managing hiccups. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114667/ [Accessed 28. 02. 2017]}

^{11. NCBI. 2013. Interventions for treating persistent and intractable hiccups in adults. Available: https://www.ncbi.nlm.nih.gov/pubmed?term=23440833 [Accessed 28. 02. 2017]}

^{12. NCBI. 2006. Acupuncture for persistent hiccups in a heart and lung transplant recipient. Available: https://www.ncbi.nlm.nih.gov/pubmed?term=16399541 [Accessed 02. 03. 2017]}

^{13. NCBI. 1966. Postoperative use of hypnosis on a cardiovascular service. Termination of persistent hiccups in a patient with an aortorenal graft. Available: https://www.ncbi.nlm.nih.gov/pubmed?term=5952844 [Accessed 02. 03. 2017]}