Hiccups are repeated involuntary spasms of the diaphragm followed by sudden closure of the glottis, which checks the inflow of air and causes the characteristic sound. Transient episodes are very common. Persistent (> 2 days) and intractable (> 1 month) hiccups are uncommon but quite distressing.
Etiology of Hiccups
Hiccups follow irritation of afferent or efferent diaphragmatic nerves or of medullary centers that control the respiratory muscles, particularly the diaphragm. Hiccups are more common among men (1).
The cause of hiccups is generally unknown, but transient hiccups are often caused by the following (2):
Gastric distention
Alcohol consumption
Swallowing hot or irritating substances
Persistent and intractable hiccups have myriad causes (see table ).
Some Causes of Intractable Hiccups
Category | Examples |
|---|---|
Esophageal | |
Abdominal | Abdominal surgery Bowel diseases Gallbladder disease Pregnancy |
Thoracic | Diaphragmatic pleurisy Thoracic surgery |
Other | Posterior fossa tumors or infarcts Uremia |
Etiology references
1. Lee GW, Kim RB, Go SI, et al. Gender Differences in Hiccup Patients: Analysis of Published Case Reports and Case-Control Studies. J Pain Symptom Manage. 2016;51(2):278-283. doi:10.1016/j.jpainsymman.2015.09.013
2. Launois S, Bizec JL, Whitelaw WA, et al. Hiccup in adults: an overview. Eur Respir J. 1993;6(4):563-575.
Evaluation of Hiccups
History
History of present illness should note duration of hiccups, remedies tried, and relationship of onset to recent illness or surgery.
Review of systems seeks concomitant gastrointestinal (GI) symptoms such as gastroesophageal reflux and swallowing difficulties; thoracic symptoms such as cough or chest pain; and any neurologic symptoms.
Past medical history should query known GI and neurologic disorders (eg, central nervous system lesion, Parkinson's disease, peripheral nerve irritation in the neck or chest) and should include details concerning alcohol use.
Physical examination
Examination is usually unrevealing but should seek signs of chronic disease (eg, cachexia). A full neurologic examination is important.
Red flags
The following is of particular concern:
Neurologic symptoms or signs
Interpretation of findings
Few findings are specific. Hiccups after alcohol consumption or surgery may well be related to those events. Other possible causes (see table ) are both numerous and rarely a cause of hiccups.
Testing
No specific evaluation is required for acute hiccups if routine history and physical examination are unremarkable; abnormalities are pursued with appropriate testing.
Patients with hiccups of longer duration and no obvious cause should have testing, including serum electrolytes, blood urea nitrogen (BUN) and creatinine, chest radiograph, and ECG. Upper GI endoscopy and esophageal pH monitoring should be considered to identify gastroesophageal reflux disease as a possible cause of hiccups. If these are unremarkable, brain MRI and chest CT may be performed.
Treatment of Hiccups
Identified problems are treated (eg, proton pump inhibitors for gastroesophageal reflux disease, dilation for esophageal stricture).
For symptom relief, some simple physical maneuvers can be tried, but they may not be effective and lack robust evidence for their use. For example, PaCO2 can be increased and diaphragmatic activity can be inhibited by a series of deep breath-holds or by breathing deeply in to and out of a paper bag. (CAUTION: Plastic bags can cling to the nostrils and should not be used.) Vagal stimulation by pharyngeal irritation (eg, swallowing dry bread, granulated sugar, or crushed ice; applying traction on the tongue; stimulating gagging) may work. Numerous other folk remedies exist.
Persistent hiccups are often recalcitrant to treatment (1). Many medications have been used in anecdotal series. Baclofen, a gamma-aminobutyric acid agonist, may be effective. Other oral medications include chlorpromazine, metoclopramide, and various anticonvulsants (eg, gabapentin). Additionally, an empiric trial of proton pump inhibitors may be given. For severe symptoms, chlorpromazine IM or IV can be given. ). Many medications have been used in anecdotal series. Baclofen, a gamma-aminobutyric acid agonist, may be effective. Other oral medications include chlorpromazine, metoclopramide, and various anticonvulsants (eg, gabapentin). Additionally, an empiric trial of proton pump inhibitors may be given. For severe symptoms, chlorpromazine IM or IV can be given.
In intractable cases, ultrasound-guided phrenic nerve blocks have been performed (2) and phrenic nerve stimulators have been used with some success (3). Phrenic nerve blocks carry the risk of respiratory depression and pneumothorax. Even bilateral phrenicotomy does not cure all cases.
Treatment references
1. Reichenbach ZW, Piech GM, Malik Z. Chronic Hiccups. Curr Treat Options Gastroenterol. 2020;18(1):43-59. Published 2020 Jan 23. doi:10.1007/s11938-020-00273-3
2. Renes SH, van Geffen GJ, Rettig HC, et al. Ultrasound-guided continuous phrenic nerve block for persistent hiccups. Reg Anesth Pain Med. 2010;35(5):455-457. doi:10.1097/aap.0b013e3181e8536f
3. Jevotovsky DS, Suarez M, Chopra H, et al. Peripheral nerve stimulation (PNS) of the phrenic nerve for intractable hiccups: a novel use case report. Reg Anesth Pain Med. 2025;50(11):916-918. Published 2025 Nov 5. doi:10.1136/rapm-2024-105796
Key Points
The cause is usually unknown.
Rarely, a serious disorder is present.
Evaluation is typically unrewarding but should be pursued for hiccups of long duration.
Numerous remedies with limited effectiveness exist, none with clear superiority.
