> Table of Contents > Hiccups
Vanessa W. McNair, MD, MPH
Jeannette M. McIntyre, MD
Steven B. Sapida, DO
image BASICS
  • Hiccups are caused by a repetitive sudden involuntary contraction of the inspiratory muscles (predominantly the diaphragm) terminated by abrupt closure of the glottis, which stops the inflow of air and produces a characteristic sound.
  • Hiccups are classified based on their duration: Acute hiccups last <48 hours; persistent hiccups last >48 hours but <1 month; intractable hiccups last for >1 month.
  • System(s) affected: nervous, pulmonary
  • Synonym(s): hiccoughs; singultus
Geriatric Considerations
Can be a serious problem, particularly among the elderly
Pregnancy Considerations
  • Fetal hiccups are noted as rhythmic fetal movements (confirmed sonographically) that can be confused with contractions.
  • Fetal hiccups are a sign of normal neurologic development (1).
  • Predominant age: all ages (including fetus)
  • Predominant sex: male > female (4:1)
Self-limited hiccups are extremely common, as are intra- and postoperative hiccups.
  • Results from stimulation of ≥1 limbs of the hiccup reflux arc (vagus and phrenic nerves) with a “hiccup center” located in the upper spinal cord and brain (2)
  • In men, >90% have an organic basis; whereas in women, a psychogenic cause is more common.
  • Specific underlying causes include the following:
    • Alcohol abuse
    • CNS lesions (brain stem tumors, vascular lesions, Parkinson disease, multiple sclerosis, syringomyelia, hydrocephalus)
    • CNS infections (encephalitis, meningitis)
    • Seizure disorder
    • Diaphragmatic irritation (tumors, pericarditis, eventration, splenomegaly, hepatomegaly, peritonitis)
    • Irritation of the tympanic membrane
    • Pharyngitis, laryngitis
    • Mediastinal and other thoracic lesions (pneumonia, aortic aneurysm, tuberculosis [TB], myocardial infarction [MI], lung cancer, rib exostoses)
    • Esophageal lesions (reflux esophagitis, achalasia, Candida esophagitis, carcinoma, obstruction)
    • Gastric lesions (ulcer, distention, cancer)
    • Hepatic lesions (hepatitis, hepatoma)
    • Pancreatic lesions (pancreatitis, pseudocysts, cancer)
    • Inflammatory bowel disease
    • Cholelithiasis, cholecystitis
    • Prostatic disorders
    • Appendicitis
    • Postoperative, abdominal procedures
    • Toxic metabolic causes (uremia, hyponatremia, gout, diabetes)
    • Drug-induced (dexamethasone, methylprednisolone, anabolic steroids, benzodiazepines, &agr;-methyldopa, propofol)
    • Psychogenic causes (hysterical neurosis, grief, malingering)
    • Idiopathic
  • General anesthesia; conscious sedation
  • Postoperative state
  • Genitourinary disorders
  • Irritation of the vagus and phrenic nerve (or branches)
  • Gastroesophageal reflux
  • Structural, vascular, infectious, neoplastic, or traumatic CNS lesions
  • Identify and correct the underlying cause if possible.
  • Avoid gastric distention.
  • Acupuncture shows promise in comparison to chronic drug therapy to control hiccups (3).
See “Etiology.”
  • Hiccup attacks usually occur at brief intervals and last only a few seconds or minutes. Persistent bouts lasting >48 hours often imply an underlying physical or metabolic disorder.
  • Intractable hiccups may occur continuously for months or years (4).
  • Hiccups usually occur with a frequency of 4 to 60 per minute (4).
  • Persistent and intractable hiccups warrant further evaluation.
  • Correlate exam with potential etiologies (e.g., rales with pneumonia; organomegaly with splenic or hepatic disease).
  • Examine the ear canal for foreign bodies.
  • Head and neck exam to look for neck masses and lymphadenopathy
  • Complete neurologic exam
Hiccups may rarely be confused with burping (eructation).
  • If history suggests an underlying etiology, consider condition-specific testing as appropriate (e.g., CBC, metabolic panel, chest x-ray).
  • Fluoroscopy is useful to determine whether one hemidiaphragm is dominant.
Diagnostic Procedures/Other
  • Upper endoscopy; colonoscopy; CT scan (or other imaging) of brain, thorax, abdomen, and pelvis looking for underlying causes
  • The extent of the workup is often in proportion to the duration and severity of the hiccups (2,5).
  • Outpatient (usually)
  • Inpatient (if elderly, debilitated, or intractable hiccups)
  • Many hiccup treatments are purely anecdotal.
  • Seek medical attention for frequent bouts or persistent hiccups.
  • Treat any specific underlying cause when identified (2, 4, 5)[C]
    • Dilate esophageal stricture or obstruction.
    • Treat ulcers or reflux disease.
    • Remove hair or foreign body from ear canal.
    • Angostura bitters for alcohol-induced hiccups
    • Catheter stimulation of pharynx for operative and postoperative hiccups
    • Antifungal treatment for Candida esophagitis
    • Correct electrolyte imbalance.
  • Medical measures
    • Relief of gastric distention (gastric lavage, nasogastric aspiration, induced vomiting)
    • Counterirritation of the vagus nerve (supraorbital pressure, carotid sinus massage, digital rectal massage)—use with caution
    • Respiratory center stimulants (breathing 5% CO2)
    • Behavioral health modification (hypnosis, meditation, paced respirations)
    • Phrenic nerve block or electrical stimulation (or pacing) of the dominant hemidiaphragm
    • Acupuncture
    • Miscellaneous (cardioversion)
First Line
Possible drug remedies (5,6,7)[B]
  • Baclofen, a GABA analog: 5 to 10 mg PO TID (2, 4, 5, 8)[B]
  • Chlorpromazine (FDA approved for hiccups): 25 to 50 mg PO/IV TID
  • Haloperidol: 2 to 5 mg PO/IM followed by 1 to 2 mg PO TID
  • Phenytoin: 200 to 300 mg PO HS
  • P.483

  • Metoclopramide: 5 to 10 mg PO QID
  • Nifedipine: 10 to 20 mg PO daily to TID
  • Amitriptyline: 10 mg PO TID
  • Viscous lidocaine 2%: 5 mL PO daily to TID
  • Gabapentin (Neurontin): 300 mg PO HS; may increase up to 1,800 mg/day PO in divided doses (4)[B]; 1,200 mg/day PO for 3 days, then 400 mg/day PO for 3 days in patients undergoing stroke rehabilitation or in the palliative care setting where chlorpromazine adverse effects are undesirable (4)[B].
  • Combination of lansoprazole 15 mg PO daily, clonazepam 0.5 mg PO BID, and dimenhydrinate 25 mg PO BID (6)[B].
  • Contraindications: Refer to manufacturer's literature.
    • Baclofen is not recommended in patients with stroke or other cerebral lesions or in severe renal impairment.
  • Precautions: Refer to manufacturer's literature.
    • Abrupt withdrawal of baclofen should be avoided.
Second Line
Possible drug therapies (2, 6, 8,9,10)[C]
  • Amantadine, carbidopa-levodopa in Parkinson disease
  • Steroid replacement in Addison disease
  • Antifungal agent in Candida esophagitis
  • Ondansetron in carcinomatosis with vomiting
  • Nefopam (a nonopioid analgesic with antishivering properties related to antihistamines and antiparkinsonian drugs) is available outside the United States in both IV and oral formulations.
  • Olanzapine 10 mg QHS
  • Pregabalin 375 mg/day
For acupuncture or phrenic nerve crush, block, or electrostimulation; cardioversion
  • Phrenic nerve crush or transaction or electrostimulation of the dominant diaphragmatic leaflet
  • Resection of rib exostoses
  • Acupuncture is increasingly used to manage persistent or intractable hiccups, especially in cancer patients (3,4)[A].
  • Simple home remedies (2,7)[C]
    • Swallowing a spoonful of sugar
    • Sucking on hard candy or swallowing peanut butter
    • Holding breath and increasing pressure on diaphragm (Valsalva maneuver)
    • Tongue traction
    • Lifting the uvula with a cold spoon
    • Inducing fright
    • Smelling salts
    • Rebreathing into a paper (not plastic) bag
    • Sipping ice water
    • Rubbing a wet cotton-tipped applicator between hard and soft palate for 1 minute
Admission Criteria/Initial Stabilization
Most patients can be managed as outpatients; those with severe intractable hiccups may require rehydration, pain control, IV medications, or surgery.
Patient Monitoring
Until hiccups cease
Avoid gastric distension from overeating, carbonated beverages, and aerophagia.
See “General Measures.”
  • Hiccups often cease during sleep.
  • Most acute benign hiccups resolve spontaneously or with home remedies.
  • Intractable hiccups may last for years or decades.
  • Hiccups have persisted despite bilateral phrenic nerve transection.
1. Witter F, Dipietro J, Costigan K, et al. The relationship between hiccups and heart rate in the fetus. J Matern Fetal Neonatal Med. 2007;20(4): 289-292.
2. Calsina-Berna A, García-Gómez G, González-Barboteo J, et al. Treatment of chronic hiccups in cancer patients: a systemic review. J Palliat Med. 2012;15(10):1142-1150.
3. Ge AX, Ryan ME, Giaccone G, et al. Acupuncture treatment for persistent hiccups in patients with cancer. J Altern Complement Med. 2010;16(7):811-816.
4. Thompson DF, Brooks KG. Gabapentin therapy of hiccups. Ann Pharmacother. 2013;47(6): 897-903.
5. Ramírez FC, Graham DY. Treatment of intractable hiccup with baclofen: results of a double-blind randomized, controlled, cross-over study. Am J Gastroenterol. 1992;87(12):1789-1791.
6. Maximov G, Kamnasaran D. The adjuvant use of lansoprazole, clonazepam and dimenhydrinate for treating intractable hiccups in a patient with gastritis and reflux esophagitis complicated with myocardial infarction: a case report. BMC Res Notes. 2013;6:327.
7. Lewis JH. Hiccups and their cures. Clin Perspect Gastroenterol. 2000;3(5):277-283.
8. Moretto EN, Wee B, Wiffen PJ, et al. Interventions for treating persistent and intractable hiccups in adults. Cochrane Database Syst Rev. 2013;(1):CD008768.
9. Marinella MA. Diagnosis and management of hiccups in the patient with advanced cancer. J Support Oncol. 2009;7(4):122-127, 130.
10. Matsuki Y, Mizogami M, Shigemi K. A case of intractable hiccups successfully treated with pregabalin. Pain Physician. 2014;17(2):E241-E242.
Additional Reading
  • Berger TJ. A rash case of hiccups. J Emerg Med. 2013;44(1):e107-e108.
  • Chang FY, Lu CL. Hiccup: mystery, nature and treatment. J Neurogastroenterol Motil. 2012;18(2): 123-130.
  • Choi TY, Lee MS, Ernst E. Acupuncture for cancer patients suffering from hiccups: a systematic review and meta-analysis. Complement Ther Med. 2012;20(6):447-455.
  • Hurst DF, Purdom CL, Hogan MJ. Use of paced respiration to alleviate intractable hiccups (Singultus): a case report. Appl Psychophysiol Biofeedback. 2013;38(2):157-160.
  • Lewis JH. Hiccups: causes and cures. J Clin Gastroenterol. 1985;7(6):539-552.
  • Rizzo C, Vitale C, Montagnini M. Management of intractable hiccups: an illustrative case and review. Am J Hosp Palliat Care. 2014;31(2):220-224.
  • R06.6 Hiccough
  • F45.8 Other somatoform disorders
Clinical Pearls
  • Most hiccups resolve spontaneously.
  • An organic cause for persistent hiccups is more likely to be found in men and individuals with intractable hiccups.
  • Rule out a foreign body in the ear canal as hiccup trigger.
  • Baclofen and gabapentin are the only pharmacologic agents proven effective in a clinical trial.
  • Acupuncture may be effective for persistent hiccups.