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Hiccups
Last reviewed: 04.07.2025
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Hiccups (singultus) are repetitive, involuntary contractions of the diaphragm followed by sudden closure of the glottis, resulting in a delay in inspiration and producing a characteristic sound. Short-lived episodes are common. Persistent (>2 days) and severe (>1 month) attacks of hiccups are rare and very bothersome to the patient.
Causes of hiccups
Hiccups are caused by irritation of the afferent or efferent phrenic nerves or the medullary centers that control the respiratory muscles, especially the diaphragm. Hiccups are more common in men.
The causes of hiccups are generally unknown, but transient hiccups are often triggered by gastric distension, alcohol consumption, or ingestion of hot or irritating substances. Persistent and severe hiccups have many etiologies, most commonly gastroesophageal reflux disease (GERD) and other esophageal disorders. Additional abdominal causes include bowel disease, pancreatitis, pregnancy, gallbladder disease, liver metastases, hepatitis, and abdominal surgery. Causes may include diseases and injuries of the thoracic and mediastinal organs, pleurisy, pneumonia, pericarditis, or diaphragmatic surgery. Metabolic disorders include uremia and alcoholism. Posterior fossa tumors or strokes may cause hiccups by stimulating centers in the medullary reticular formation.
Evaluation and treatment of hiccups
In acute episodes of hiccups, no specific evaluation is required unless the routine history and physical examination reveal abnormalities; abnormalities identified require appropriate testing. Prolonged hiccups and no apparent cause require testing including serum electrolytes, blood urea nitrogen, and creatinine, chest x-ray, and electrocardiography. Upper gastrointestinal endoscopy should be performed, and esophageal pH monitoring should be performed if possible. If abnormalities are not found, brain MRI and chest CT may be done. Abnormalities identified require treatment (eg, proton pump inhibitors for GERD, dilation of esophageal stricture).
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Symptomatic treatment of hiccups
Treatment of hiccups involves the use of many simple measures, but none of them is sufficiently effective: increasing the partial pressure of CO2 inhibits the contractile activity of the diaphragm, which is achieved by a series of deep breath holds or deep breathing into a paper bag.
CAUTION: Plastic bags may block the nostrils and should not be used.
Stimulation of the vagus nerve by swallowing movements (e.g., swallowing dry bread, granulated sugar, or crushed ice, traction on the tongue, stimulation of gagging movements) may be effective. There are numerous other folk remedies.
Persistent hiccups are often resistant to treatment. Many different medications have been recommended. Baclofen, a y-aminobutyric acid agonist, 5 mg orally every 6 hours, increasing to 20 mg per dose, may be effective. Other drugs include chlorpromazine 25-50 mg intravenously every 6 hours, metoclopramide 10 mg orally 4 times a day, and various antispasmodics. Proton pump inhibitors may also be used empirically. In severe cases, phrenic nerve block with small doses of 0.5% procaine solution may be used, taking care to avoid respiratory failure and pneumothorax. Even bilateral phrenicotomy is not always effective.