Hiccups
Introduction
A hiccup occurs due to an involuntary, intermittent, spasmodic contraction of the diaphragm and intercostal muscles.
- Although hiccups most commonly are self-limited (last for <48 hours), they can become prolonged and decrease quality of life by interrupting eating, drinking, sleeping and conversation; exacerbating pain; causing insomnia, fatigue and mental stress; or adversely affecting moods.
- Hiccups lasting >48 hours are classified as persistent, while those lasting >1 month are considered intractable.
Management
Treatment of hiccups should be focused on the underlying cause when possible.
- For patients not known to have an advanced malignancy and who experience hiccups lasting more than 48 hours, a thorough history, physical examination and some laboratory testing should be performed to try to determine the underlying aetiology, even though in many patients a specific cause is not found.
- Medications associated with hiccups include dexamethasone, diazepam, midazolam, barbiturates, tramadol, certain anti-cancer drugs (e.g. levofolinate, fluorouracil, oxaliplatin, carboplatin, irinotecan) and alpha methyldopa.
Prior to considering medications, physical manoeuvres to interrupt the hiccup reflex arc or respiratory function may be attempted by the patient.
- Breath holding for 5 to 10 seconds (or as tolerated)
- Performing Valsalva manoeuvre, holding for five seconds
- Sipping or gargling with very cold water
- Swallowing items that are difficult to swallow, such as granulated sugar, peanut butter or molasses
- Forceable traction (i.e. pulling) on the tongue
- Biting into a lemon
- Pressing gently but firmly on the eyeballs
- Induce sneezing
- Compressing the diaphragm by pulling knees to the chest or leaning forward for 30 seconds to 1 minute if possible.
- Drinking water through a forced inspiratory suction and swallow device (i.e. a rigid tube with a valve that requires significant suction effort)
Drugs reported to beneficial in the treatment of hiccups include dopamine antagonists (e.g. metoclopramide, haloperidol, chlorpromazine) and GABA agonist (e.g. baclofen, gabapentin).
- Based on limited efficacy and safety data, a 2015 systematic review recommended that baclofen and gabapentin may be considered first-line therapy for persistent and intractable hiccups, followed by metoclopramide and chlorpromazine.
NOTE: Chlorpromazine is the only FDA approved drug for intractable hiccups but may be unacceptable for many patients due to potential adverse effects, such as hypotension, urinary retention, delirium, dystonic reactions and drowsiness.
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