Approach

In most patients, hiccups are benign and self-limiting or cured with simple home remedies and do not require any medical intervention. Pharmacological and more invasive treatments should be reserved for the rare patients who have chronic hiccups, for symptomatic relief and for avoidance of potential complications.

Treatment should be guided by the duration and intensity of the hiccups and initiated by a specialist physician. The associated risks of invasive treatment should be weighed against the foreseen benefits, to avoid a generally benign condition resulting in serious, treatment-related complications.

Factors known to predispose to hiccups, such as excessive food or alcohol consumption, drinking carbonated beverages, sudden changes in ambient or gastrointestinal temperature (e.g., cold showers, drinking hot or cold beverages), sudden excitement, and emotional stress, should be avoided in all patients.[5]

Valid scientific data regarding the treatment of hiccups are difficult to find.[21] The vast majority of evidence for treatments of hiccups has come from uncontrolled observational trials or case-control series or reports. Valid randomised placebo-controlled trials are needed.

Home remedies

Several home remedies, used alone or in combination, are usually effective in curing episodes of benign hiccups. These include breath holding, the Valsalva manoeuvre (a forced expiration against a closed glottis), breathing into a paper bag, pulling on the tongue, sneezing, swallowing a teaspoon of granulated sugar, sipping iced water, compressing the diaphragm by pulling the knees up to the chest, swallowing large amounts of water while closing the nose and ears, and a sudden fright.

Treatment of underlying cause

Successful treatment of the underlying cause of chronic hiccups may lead to termination of these hiccups.[22] If hiccups persist despite specific therapy, physical manipulation should be attempted.[23]

If dexamethasone is deemed to be the causative drug, the use of another corticosteroid should be considered if possible as it could result in hiccup relief.[24]

Some clinical evidence suggests that using a straw-like device to drink water and tasting a sour substance might also be helpful.[25][26] However, these interventions require further testing to demonstrate their efficacy.

Physical manipulation

Interruption of the hiccup reflex arc leads to termination of hiccups and can be achieved through several techniques. Stimulation of the nasopharynx with a finger, rubber catheter, or cotton-tipped applicator, lifting the uvula, or inducing a gasp by smelling salts or other noxious agents can be tried.[27]

Second-line techniques include carotid sinus massage, applying supraorbital pressure, digital compression to the root of the neck over the course of the phrenic nerve, and compression of the thyroid cartilage.[28] These procedures are not without risk and should be pursued only with extreme caution. Vagal manoeuvres can lead to severe bradycardia, and the application of noxious agents can cause local adverse effects such as corrosion. 

Nasogastric aspiration and manipulation of the auditory canal can also be employed. Treatment of hiccups with digital rectal massage and sexual intercourse is also documented.[29][30]

As physical manipulation techniques are associated with potential harmful effects, they should only be attempted once less invasive measures have failed.

Pharmacotherapy

Chronic hiccups unresponsive to physical manipulation often require pharmacological therapy. The use of baclofen is supported by two small randomised trials.[31][32] Other agents such as chlorpromazine and metoclopramide have been tried with success in small studies, but they are limited by their side effect profiles.[33][34][35] No agent has proven, well-established efficacy.[27][36]

Alternative therapies

In addition to conventional physical manipulation techniques and pharmacotherapy, alternative therapies such as acupuncture, hypnosis, and psychotherapy can be tried for chronic hiccups.[1][30][37] 

Invasive therapy

In refractory hiccups associated with significant discomfort and morbidity, disruption of the phrenic nerve (i.e., the efferent branch of the hiccup reflex arc) may be considered. Permanent phrenic nerve crush or transection should be preceded by a nerve block with a long-acting local anaesthetic. Before treatment, which leaflet of the diaphragm is contracting has to be established, and the phrenic nerve responsible for the unilateral contraction must be identified clearly by means of nerve stimulation. As serious impairment of pulmonary function can occur after diaphragmatic paralysis, this procedure is only justified in extreme cases, and all other possible conservative treatments, including alternative therapies, should be exhausted before embarking on phrenic nerve disruption.[1][30]

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