Ep 215 – Hiccups

Hiccups are a common symptom, with short-lived episodes usually being a source of amusement rather than distress. For these acute episodes, simple nonpharmacologic techniques are often effective. However, persistent hiccups greatly affect quality of life and can be difficult to manage. There is often significant diagnostic dilemma, with potentially serious and even life-threatening underlying causes needing to be considered. In this episode, Dr Kate Chesterman discusses the investigation and management of hiccups.

Key take-home points

• Most hiccups lasting less than 48 hours are benign and self-limiting, so reassurance, trigger avoidance and simple self-help measures are usually enough.
• Hiccups persisting beyond 48 hours should prompt assessment for an underlying cause, especially if they are distressing, recurrent or if they are affecting sleep, nutritional intake or hydration.
• The causes of persistent hiccups can be classified as peripheral, central, metabolic, drug-induced and psychogenic and over 100 aetiologies have been identified. However, in many cases the cause remains unknown.
• A thorough history should include the duration of symptoms, potential triggers and a systems review to identify associated gastrointestinal, respiratory, cardiovascular and neurological symptoms, red flags and medication causes including steroids, benzodiazepines, opioids and alcohol.
• Examination should include ear nose and throat, chest, abdominal and neurological assessment.
• Initial primary care investigations may include full blood count, urea and electrolytes, calcium, liver function tests, amylase, C-reactive protein, chest X-ray and electrocardiogram, guided by the clinical picture.
• If reflux or gastric distension is suspected, a trial of treatment in primary care may be reasonable, for example with a proton pump inhibitor, antacid or metoclopramide where appropriate.
• Refer urgently if there are red flags, concern about serious underlying pathology, significant weight loss, neurological features or a need for imaging or specialist management.
• Drug treatment for persistent hiccups is usually reserved for cases not responding to simple measures and often needs specialist advice. Good quality evidence for pharmacological therapy is lacking but baclofen, chlorpromazine and metoclopramide have been tried with some success. Benzodiazepines should be avoided as they may worsen symptoms.
• Arrange review within a few days for patients started on treatment or with ongoing symptoms, to confirm improvement and reconsider the diagnosis or referral if not settling.
• Around 4–5% of patients with advanced cancer are affected by persistent and distressing hiccups. Gastric stasis and distension as well as metabolic disturbances and nerve compression or irritation from hepatic, mediastinal or cerebral tumours are possible causes.
• Palliative-care teams can offer invaluable advice and an early discussion with them can be extremely beneficial.

Key references

1. BMJ Best Practice. 2026. https://bestpractice.bmj.com/topics/en-gb/1040.
2. NHS. 2023. https://www.nhs.uk/symptoms/hiccups/.
3. Quiroga JB, et al. Br J Gen Pract. 2016;66(652):584-586. doi: 10.3399/bjgp16X687913.
4. Scottish Palliative Care Guidelines https://www.rightdecisions.scot.nhs.uk/scottish-palliative-care-guidelines/scottish-palliative-care-guidelines/symptoms/symptom-management/hiccups/?searchTerm=hiccups.
5. Woelk CJ. Can Fam Physician. 2011;57(6):672-675, e198-201.
6. Wilkes G. 2023. https://emedicine.medscape.com/article/775746-overview.