Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

benign hiccups

1st line – home remedies

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ACUTE
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benign hiccups
1st line – 

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 maneuver (a forced expiration against a closed glottis), breathing into a paper bag, pulling on the tongue, sneezing, swallowing a teaspoon of granulated sugar, sipping ice 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.

Plus – avoidance of precipitating factors

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ACUTE
|
benign hiccups
Plus – 

avoidance of precipitating factors

Treatment recommended for ALL patients in selected patient group

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]

ONGOING

chronic hiccups

1st line – treatment of underlying cause

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ONGOING
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chronic hiccups
1st line – 

treatment of underlying cause

Successful treatment of the underlying cause of chronic hiccups may lead to termination of these hiccups.[23] If hiccups persist despite specific therapy, physical manipulation should be attempted.[24]

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.[25]

Some clinical evidence suggests that using a straw-like device to drink water and tasting a sour substance might also be helpful.[26][27] However, these interventions require further testing to demonstrate their efficacy.

2nd line – physical manipulation

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ONGOING
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chronic hiccups
2nd line – 

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.[28]

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.[29] These procedures are not without risk and should be pursued only with extreme caution. Vagal maneuvers 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.[30][31]

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

Consider – alternative therapies

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ONGOING
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chronic hiccups
Consider – 

alternative therapies

Treatment recommended for SOME patients in selected patient group

In addition to conventional physical manipulation techniques, alternative therapies such as acupuncture, hypnosis, and psychotherapy can be tried for chronic hiccups.[1][31][38] 

3rd line – pharmacotherapy

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ONGOING
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chronic hiccups
3rd line – 

pharmacotherapy

Chronic hiccups unresponsive to physical manipulation often require pharmacologic therapy. The use of baclofen is supported by two small randomized trials.[32][33] Other agents such as chlorpromazine and metoclopramide have been tried with success in small studies, but they are limited by their side effect profiles.[34][35][36] No agent has proven, well-established efficacy.[28][37]

Primary options

baclofen: consult specialist for guidance on dose

Secondary options

chlorpromazine: consult specialist for guidance on dose

OR

metoclopramide: consult specialist for guidance on dose

Consider – alternative therapies

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ONGOING
|
chronic hiccups
Consider – 

alternative therapies

Treatment recommended for SOME patients in selected patient group

In addition to conventional physical manipulation techniques and pharmacotherapy, alternative therapies such as acupuncture, hypnosis, and psychotherapy can be tried as possible conservative treatments for chronic hiccups.[1][31][38]

4th line – phrenic nerve disruption

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ONGOING
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chronic hiccups
4th line – 

phrenic nerve disruption

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 anesthetic. 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][31]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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