What’s up with hiccups?

Robert H. Shmerling, MD
Robert H. Shmerling, MD, Faculty Editor, Harvard Health Publications

Follow me on Twitter @RobShmerling

If you do an Internet search on “hiccups” you’ll find lots of supposed cures for this annoying but usually fast-passing condition — one site lists 250 of them! One thing you won’t find, though, is a good reason for why we hiccup.

Hiccupping is a more complex reflex than it might seem: a sudden contraction or spasm of the diaphragm and the muscles between the ribs makes you inhale quickly and involuntarily. It ends with “glottic closure” — the space in the throat near the vocal cords snaps shut, producing the typical hiccup sound. The technical term for hiccups (singultus) comes from a Latin word (singult) that means catching your breath while crying, which seems like a pretty good description of the sound of hiccupping.

In most cases hiccups seem to serve no purpose and go away on their own, usually after 30 or more hiccups. Any of the following may cause a short bout of hiccups:

  • an overly full stomach, due to too much food, too much alcohol, or too much air in the stomach
  • sudden changes in temperature, either outside your body or internally
  • smoking cigarettes
  • excitement, stress, or other heightened emotions.

Making hiccups go away

Of the many, many ways to get rid of hiccups, here are a few you can try that are logical, considering the muscles and tissues involved:

  • Stimulating the nasopharynx, or the uppermost region of the throat, by pulling on your tongue, swallowing granulated sugar, gargling with water, sipping ice water, drinking from the far side of a glass, or biting on a lemon (not all at once, of course)
  • Stimulating the skin that covers the spinal nerves near the neck by tapping or rubbing the back of the neck
  • Stimulating the pharynx, or back of the throat, by gently poking it with a long cotton swab
  • Interrupting your normal respiratory cycle by holding your breath, breathing into a paper bag (which increases the amount of carbon dioxide you inhale), gasping in fright, or pulling your knees up to your chest and leaning forward
  • Distracting your mind from the fact that you have the hiccups.

And when hiccups won’t go away…

Occasionally, hiccups just won’t go away. A farmer in Iowa reportedly had hiccups for 60-plus years. Imagine that annoying, interrupting gasp for air coming every few seconds for 60 years! Luckily, even long-lasting hiccups don’t usually signal a medical problem. Very rarely, though, persistent hiccups may be a sign of disease, usually something that causes irritation of one of the nerves in the chest. Examples include laryngitis, goiters (enlargement of the thyroid gland), tumors in the neck, infections near the diaphragm, and hiatal hernia (usually accompanied by heartburn). Hiccups can also be triggered by excess alcohol use, kidney failure, and infections (especially ear infections). Rarer causes are aortic aneurysms and multiple sclerosis.

Persistent hiccups can also cause problems of their own. Think about it — hiccupping can make it difficult to eat, drink, and sleep, all things you need to do to keep healthy.

If you have hiccups that won’t go away on their own, your doctor will look for problems that may be causing them, and then try to fix that problem. Your doctor may also prescribe a medication (there are some that can reduce hiccups) — or tell you to stop taking a particular drug, because there are medications that can set off the hiccups.

Surgery for persistent hiccups is also an option, though one that’s exercised rarely. Two examples are a “nerve block” that stops the phrenic nerve (the major nerve supply for the diaphragm) from sending signals so that the diaphragm stops contracting, and implantation of a pacemaker to make the diaphragm contract in a more rhythmic pattern.

The bottom line

So, to review: we don’t know why we hiccup and we don’t know how to reliably get rid of them. They are as mysterious as they are universal. And it seems that just about everyone has a cure. Here’s my favorite: waiting a few minutes.

Related Information: Harvard Men’s Health Watch

Comments:

  1. Mike Forbes

    Drug Therapy of Hiccups

    Full update March 2017
    Hiccups, the involuntary contraction of the diaphragm, are common.1 Hiccups are caused by anything that stimulates the hiccup reflex arc. Acute hiccup attacks last less than 48 hours, while persistent hiccups last longer. Intractable hiccups are defined as an attack lasting more than one month.1,2 Although the incidence and prevalence are not known, one retrospective chart review found that of 100,000 consecutive patient visits to a hospital, 55 were for hiccups.3 Persistent hiccups may be a sign of an underlying problem. Before initiating medications to treat hiccups, correctable causes for hiccups should be investigated. Examples of underlying causes of hiccups include CNS abnormalities (e.g., meningitis, intracranial tumors, etc), gastrointestinal issues (e.g., peptic ulcer, gastroesophageal reflux disease, abdominal abscess, etc), thoracic diseases (e.g., pneumonia, asthma, etc), abnormalities of the ears-nose-throat (e.g., rhinitis, otitis media, etc), toxic exposures or metabolic derangements (e.g., alcohol, electrolyte abnormalities, etc), psychogenic causes (e.g., stress, fear, excitement, etc), post-surgical causes (e.g., anesthetic agents, pharyngeal intubation, etc), and medications (e.g., corticosteroids, opioids, benzodiazepines, etc).1,2,4 Pharmacological therapy should only be used if persistent hiccups are causing distress. Although home remedies such as breath holding, swallowing a spoonful of sugar, or drinking pickle juice are sometimes tried, the evidence to support these methods is scant. The table below summarizes drugs which have been used in the treatment of hiccups. Most of the treatments can be used for seven to ten days but can be discontinued one or two days after hiccups cease.4 If hiccups continue despite treatment, it is reasonable to consider a different medication.4 Of note, two different recent systematic reviews of the literature found no high quality data on which to base treatment recommendations.1,5

    Abbreviations: GERD=gastroesophageal reflux disease; IM=intramuscular; IV=intravenous; PO=by mouth

    *Most of the drugs below are used off-label for the treatment of hiccups. Dosing regimens will vary depending on the source*

    Drug

    Example Regimen(s)1,2,4

    Comments
    Antidopaminergic agents

    Chlorpromazine

    25 mg to 50 mg PO three to four times a day4,13

    If symptoms persist after two to three days: 25 mg to 50 mg IM x113

    If IM dose fails, try 25 mg to 50 mg IV administered as a slow IV infusion (max 1 mg/min) with the drug diluted in 500 to 1000 mL saline.13

    Chlorpromazine is the only medication approved by the FDA for the treatment of intractable hiccups (it is not approved for this indication by Health Canada), but there are only observational data to support the use.1,6

    May reverse the abnormal depolarization in the hiccup reflex arc.2

    Concern about QTc prolongation, hypotension (especially with IV doses), others.4

    Concern about movement disorders with prolonged use.12

    Monitor blood pressure with IV administration.13

    Haloperidol

    2 mg to 5 mg IM,13,14 then
    1 mg to 4 mg PO three times daily14

    May be a safer alternative to IV chlorpromazine (less hypotension).13

    Limited information (case reports, case series) to support use.10

    Concern about QTc prolongation.4

    Concern about movement disorders with prolonged use.12

    Metoclopramide

    10 mg PO or 5 mg to 10 mg IV/IM three to four times daily

    Lower quality, small, randomized, controlled trials and case series available to support the use.1,4

    May reduce the intensity of esophageal contractions.2

    Concern about QTc prolongation.9

    Concern about movement disorders with prolonged use.1

    Theoretically, domperidone (Canada only) should be effective, but there are no studies supporting its use.1

    GABA analogs

    Baclofen

    5 mg to 10 mg PO three times a day

    Some experts consider baclofen a first-line therapy because during long-term therapy it’s less likely to cause adverse effects compared with antidopaminergic agents.1,2

    Lower quality, small, randomized, controlled trials available to support the use.1

    May reverse the abnormal depolarization in the hiccup reflex arc or affect GABA transmission.2

    May cause drowsiness and dizziness.4

    Gabapentin

    900 mg to 1200 mg/day; in divided doses

    Some experts consider gabapentin a first-line therapy because during long-term therapy it’s less likely to cause adverse effects compared with antidopaminergic agents.1

    Only case series and case reports available to support the use.1

    May enhance GABA transmission centrally.1

    May cause drowsiness and dizziness.4

    Antiepileptic agents

    Carbamazepine

    100 mg to 300 mg PO up to four times a day

    Only case series and case reports available to support the use.1

    May inhibit excitatory sodium channels on central neurons.1

    May cause dizziness, nausea, vomiting.12

    Phenytoin

    100 mg PO three times daily

    Use based on expert opinion; limited evidence to support the use.1

    May inhibit excitatory sodium channels on central neurons.1

    May cause dizziness, drowsiness.12

    Valproate

    Dose titration up to 20 mg/kg/day

    Only case series and case reports available to support the use.1

    May enhance GABA transmission centrally.1,2

    May cause dizziness, drowsiness, nausea, vomiting.12

    Miscellaneous Agents2

    Nifedipine

    20 mg to 60 mg/day PO

    Only case series and case reports available to support the use.1

    May reverse the abnormal depolarization in the hiccup reflex arc.2

    Amitriptyline

    25 mg to 100 mg/day PO

    Use based on expert opinion; limited evidence to support the use.1

    Proton pump inhibitors (omeprazole, others)

    GERD treatment doses11

    One large case series of proton pump inhibitors showed benefit in patients with hiccups related to gastroesophageal reflux disease. However, there was no control group and it is not known if the hiccups were due to GERD or if hiccups were the cause of GERD.1

    Other medications which have been tried for hiccups include midazolam, clonazepam, pramipexole, olanzapine, amantadine, sertraline, risperidone, methylphenidate, viscous lidocaine and methylcellulose.7,8

  2. Km

    Good article , gives many practical remedies for medicine related hiccups.

  3. Glen

    To get rid of hiccups, stand up and arch your head backward to stretch/ tighten the abdominal muscles. Put hands behind your head & hold that position for 30-60 seconds. Works for me.