Hiccoughs

Hiccupping is a pathological respiratory reflex. It can be an intractable and uncomfortable symptom in palliative care.

Causes

• Diaphragm or phrenic nerve irritation e.g. gastric distension, hepatomegaly
• Cerebral irritation e.g. tumour or stroke
• Metabolic changes e.g. uraemia, hypocalcaemia

Non-drug treatments

• Treatment of identified causes
• Pharyngeal stimulation e.g. sipping cold water
• Valsalva manoeuvres 
• Raising PCO2 via breath holding or rebreathing into a paper bag can inhibit the hiccup reflex
• Complementary therapy such as acupuncture or reflexology 

Drug treatments

• Prokinetics can reduce gastric distension (e.g. domperidone)
• Proton pump inhibitors and antacids can reduce gastric irritation
• Muscle relaxants including baclofen and benzodiazepines 
• Central suppression of the hiccup reflex may be achieved by haloperidol 1.5 mg - 3mg at night, chlorpromazine 25 mg three times a day or gabapentin 400 mg three times a day for 3-day course
• Some anti-epileptic drugs have been shown to be beneficial e.g. sodium valproate or carbamazepine
• Referral for phrenic nerve block may be appropriate