Medical Edge Newspaper Column

When Hiccups Hang On

August 20, 2007
Dear Mayo Clinic:
How can hiccups be prevented? What treatments are available if they don't go away? -- Parker, Colo.

Answer:
Hiccups are rarely a cause for concern, and most of the time they disappear on their own within minutes. Still, hiccups can be embarrassing, inconvenient, and annoying, especially if they do continue beyond a very short period.

Because there is no incontrovertible "cure" for this condition, it makes eminent sense to want to prevent it in the first place. The problem is, aside from a few basic facts, the exact mechanism is poorly understood, and so a truly fail-safe way of preventing hiccups is not available.

We do know that hiccups result from an unintentional contraction, or spasm, of the diaphragm, a muscle that separates the chest from the abdomen. We also know that the paired phrenic nerves (one on each side) control the diaphragm's contractions, and that the similarly paired vagus nerves, which deliver stimuli from elsewhere in the body, can irritate the phrenic nerves.

Certain factors may trigger "transient" hiccups (lasting from a few minutes to as long as 48 hours), either by irritating the phrenic nerves or by causing the stomach to expand, which pushes up the diaphragm and makes hiccups more likely. Eating spicy food, eating a large meal, eating too quickly, drinking carbonated beverages, drinking alcohol, swallowing air, sudden temperature changes, tobacco use, and sudden excitement or emotional stress have all been implicated and might well be avoided as much as possible. But some of these phenomena are easier to limit than others, and there's no guarantee that avoiding any of them will prevent an individual's hiccups. In fact, the cause of any single bout usually remains unknown.

This brings us to treatment, which includes doing nothing and simply waiting it out, as the episode is most likely to be fleeting. If it is not, then additional options -- of the "home remedy" kind -- are available. The long list includes, but is not limited to, swallowing a teaspoon of sugar, eating a bit of fresh ginger, sucking on a lemon, eating ice, having a hot-water-and-honey drink, drinking a glass of cold water, gargling, holding your breath for a count of 10, breathing temporarily into a paper bag, gently massaging the roof of your mouth with a cotton swab, sitting down and leaning forward over your knees, or having someone startle you.

Some of these options work quite well for certain individuals, who often will swear by them, yet prove ineffective for others. It's a matter of trial and error to find an approach that suits you best. There is no scientific backing for any of them, except to say that in one way or another they may ease or counter the irritation of the diaphragm-controlling nerves. And given that hiccups may sometimes be caused or exacerbated by emotional factors, even a placebo effect could be quite helpful.

In the unlikely event that hiccups are "persistent" (lasting more than 48 hours) or "intractable" (more than a month), they may be the result of an underlying medical condition -- such as a cyst in the neck or chest, a central nervous system disorder, or a post-surgical complication -- that should be addressed directly.

Meanwhile, treatments for long-lasting hiccups are available that relieve the symptom -- they reduce the hiccupping. Drugs that have proven effective include psychiatric drugs, used off-label, such as the antipsychotic chlorpromazine (Thorazine) and the antidepressant amitriptyline (Elavil). The muscle relaxant baclofen (Lioresal) and the antiemetic metoclopramide (Reglan) have also been successful in treating persistent or intractable hiccups.

Non-drug options that are reported to work for long-term hiccups include massage of the carotid sinus (located in the neck just below the jaw) by a health care provider; injection of an anesthetic to block the phrenic nerve; and implantation of a specialized pacemaker that regulates the diaphragm's movement. Alternative treatments such as acupuncture and hypnosis also may be helpful.

-- Udaya B.S. Prakash, M.D., Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minn.