Hiccups: More Than a Nuisance? A Medical Perspective

What's your tried and true hiccup quick fix? Do you drink a glass of water upside-down? Or, maybe you're more of a believer in swallowing a spoonful of peanut butter (mmmm...). We've all heard of wacky ways to cure a persistent case of the hiccups. One company has even commercialized the problem creating a "Hiccup Stick". Wive's tales aside, there is actually a medical explanation for why hiccups occur and formal recommendations for their treatment. 

Hiccups aren't a problem for which most people seek medical help. But, there can be cases where the annoying problem just won't go away. If a patient presents to your clinic or emergency department with a nasty case, do you know what to do?

What are hiccups, anyway?

Medically speaking, hiccups are known as SDF (synchronous diaphragmatic flutter). In SDF the diaphragm and larynx contract simultaneously which closes the glottis and blocks air intake. This action closes the vocal cords creating a 'hic' sound.

Hiccups can occur individually or in bouts, lasting minutes to months. When hiccups occur in bouts, they occur rhythmically at relatively consistent intervals at anywhere from 4 to 60 hiccups per minute. Bouts that do not resolve after one month are considered to be intractable (can you imagine?!). 

Hiccups are more common in men than women. 82% of cases of intractable hiccups occur in males. Hiccups are also more likely to occur in evening hours for both sexes and during the first half of the menstrual cycle in women. They can occur at any age. In fact, it is estimated that preterm infants spend 2.5% of their time hiccuping. 

What causes hiccups?

Hiccups can be caused by both physiologic or psychologic processes. The most common causes of hiccups include:

  • Consumption of hot food that irritates the phrenic nerve
  • Eating too much food or eating food too rapidly
  • Gas in the stomach pressing against the diaphragm
  • Fizzy drinks
  • Sudden changes in temperature
  • Medications such as opiates, benzodiazepines, corticosteroids, anesthesia, and barbiturates

Persistent hiccups can be a symptom of a more serious medical problem. Causes of persistent or intractable hiccups include:

  • Problems of the central nervous system such as malignancy, multiple sclerosis, infection, trauma, or vascular lesions
  • Conditions that irritate the diaphragm like a hiatal hernia, subphrenic abscess, myocardial infarction, or pericarditis
  • Vagus nerve irritation related to meningitis, foreign body ingestion, pharyngitis, mass, or abdominal pathology
  • Metabolic problems such as hyponatremia, hypokalemia, hypocalcemia, uremia, hyperglycemia, or hypocarbia
  • Psychologic causes such as anxiety, stress, excitement, shock, hysterical behavior, or grief

How do you determine the cause of hiccups?

Anyone can diagnose hiccups, it's treating them that's the trick. In patients with persistent hiccups, a thorough exam and workup is warranted to rule out a potentially serious cause of the problem. Lab studies including checking electrolytes, renal and liver function, as well as a white blood cell count should be done. In cases where infectious disease is a possibility, urine and sputum collection as well as CSF collection should be considered. Imaging studies such as a chest X-ray and/or CT scan of the head, thorax, and abdomen can be helpful in ruling out infection and tumor. MRI may be useful in ruling out causes such as multiple sclerosis, and pathology of the vagus and phrenic nerves. 

In many cases, the cause of hiccups is not found. This is especially true in children and in cases that resolve spontaneously within a few minutes. 

Treating Hiccups

Interestingly, many home remedies are effective in treating simple cases of hiccups. These remedies are typically methods of increasing the level of carbon dioxide in the blood. Effective home remedies for treating hiccups include:

  • Breath holding, hyperventilation, gasping, or breathing into a paper bag
  • Pulling the knees to the chest and leaning forward
  • Vagal stimulation using the valsalva maneuver or rectal massage (I'll try holding my breath, thank you) 
  • Stimulating the nasopharynx by applying traction to the tongue and swallowing granulated sugar, gargling water, sipping ice water, biting a lemon, or inhaling noxious agents

Occasionally, treatment of hiccups requires pharmacologic intervention. Drugs effective in relieving hiccups include:

  • Chlorpromazine, the drug of choice for alleviating hiccups
  • Haloperidol
  • Metclopramide
  • Gabapentin
  • Baclofen

In very rare cases, surgical intervention is required. Phrenic nerve ablation can alleviate hiccups but carries serious risks including respiratory complications. 

Have you ever treated a case of intractable hiccups?

 

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