The Hospice Clinician Blog

A hiccup is an involuntary reflex involving the respiratory muscles of the chest and diaphragm, mediated by the phrenic and vagus nerves and a central (brainstem) reflex center. A single episode can last for a few seconds to as long as several days. Persistent hiccups can last for months. There are a wide range of possible causes for hiccups including; stress or excitement, esophageal or gastric distension, liver disease, CNS lesions, or cancer. Irritation of the vagus nerve or the diaphragm is a common mechanism.

Many drug and non-drug treatments have been used, but there is little evidence of any one superior approach to management; virtually all current data are anecdotal. When choosing a drug treatment strategy, consider the hospice patient's drug allergy history, potential drug-disease state contraindications, current level of function, and potential adverse effects from any proposed drug therapy.

Chlorpromazine (Thorazine) is the only drug with an FDA approved indication for treatment of hiccups. Haloperidol (Haldol) is a useful alternative. Chlorpromazine and Haloperidol should not be used in hospice patients with Parkinson's disease because they may exacerbate involuntary movements. Metoclopramide (Reglan) increases GI motility and may be especially useful if hiccups are related to esophageal or gastric distention. The muscle relaxant, Baclofen (Lioresal), is thought to have a direct relaxation effect upon the diaphragm and may be most useful in patients where an irritation of the diaphragm is suspected. Dexamethasone (Decadron) may be appropriate as an adjunct to one of the previously mentioned drugs if there is hepatomegaly or tumor involvement. All of these drugs are available as low cost generics, so the choice of therapy should be based upon the suspected etiology behind the hiccups, the hospice patient's drug allergy history, and other health conditions that may predispose the patient to adverse drug effects.

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