A wide variety of physical maneuvers have been used to terminate an acute episode of hiccups. Many of these measures are based on the concept that stimulating the pharynx will block the vagal portion of the reflex arc and abolish the hiccups. 27 No one method appears to be more effective than another. Swallowing a teaspoon of granulated sugar dry is about as effective as others and does not involve the infliction of noxious or painful stimulation.

Drug treatment also works by inhibiting the reflex arc. 27 A large number of agents have been described as effective, but mostly only as case reports. Of the recommended drugs, only chlorpromazine has been tried enough to have achieved US Food and Drug Administration approval for treatment of intractable hiccups. The recommended dose is 25 to 50 mg intravenously, with a repeated dose in 2 to 4 h if needed. If improvement is noted, oral therapy with 25 to 50 mg tid or qid should be given. Metoclopramide 10 mg intravenously or intramuscularly and, if effective, followed by 10 to 20 mg qid for 10 days appears to be effective. The advantage of both these drugs is that effectiveness is usually evident in 30 min, unlike with other agents. The major disadvantages are extrapyramidal symptoms with both drugs and hypotension with chlorpromazine.

For more gradual control and with perhaps less risk of adverse reactions, oral treatment can be initiated with nifedipine (10 to 20 mg tid or qid), valproic acid (15 mg/kg per day taken tid), or baclofen (10 mg tid). Initiation and maintenance of these agents is best done in concert with a primary care physician who will follow up with the patient.

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