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Am Fam Physician. 2001;63(9):1684-1686

to the editor: Hiccups are an annoyance to nearly everyone at one time or another. Fortunately, they are also usually self-limited and benign. It is unusual for persons to seek care for hiccups unless the episode is particularly prolonged. Prolonged hiccups, however, can be debilitating and may be a sign of serious underlying disease. Thus, when patients do present with hiccups for medical attention, it is important to evaluate for potentially serious underlying causes.

Hiccups are believed to be caused mainly by irritation of either the phrenic or vagus nerves anywhere along their paths.1 Central nervous system diseases, toxins, drugs and metabolic abnormalities may also lead to hiccups. The accompanying table1 lists some of the many diseases that have been reported to cause hiccups.

Hiccups lasting longer than two days are termed “persistent” and those lasting longer than one month are considered “intractable.”1 Intractable hiccups will frequently be a sign of underlying organic disease1; therefore, obtaining a thorough history and performing a physical examination is important to evaluate for potentially serious causes. The most useful studies are probably a chest radiograph and an electrolyte panel. Further studies can be ordered based on findings from the history and physical examination.

Many pharmacologic and nonpharmacologic remedies have been used to try to abort hiccups. Medications that have been reported to be effective include chlorpromazine (Thorazine),1,2 nifedipine (Procardia),3 haloperidol (Haldol),1,4 phenytoin (Dilantin),1 metoclopramide (Reglan),1 baclofen (Lioresal)1,5 and gabapentin (Neurontin).6 Surgical management has included such techniques as phrenic nerve interruption or placement of diaphragmatic pacemakers.1 Stimulating the nasopharynx with a rubber catheter and elevating the uvula with a cotton tip applicator or similar device have both been reported to be efficacious in the alleviation of hiccups.1

Gastric distension
Excessive food or alcohol intake
Gastric insufflation
Sudden changes in gastric temperature
Ingestion of hot or cold foods
Moving from a hot to a cold area or vice versa
Tobacco use
Alcohol intoxication
Central nervous system
Arteriovenous malformation
Cerebral contusion or hematoma
Temporal arteritis
Encephalitis or meningitis
Multiple sclerosis
Head trauma
Peripheral nervous system (secondary to irritation of vagus or phrenic nerves)
Head and neck tumors
Mediastinal or lung masses

Of any malady in medicine, hiccups probably have some of the most interesting home remedies. Perhaps the most well-known home remedy is breathing into a paper bag. This method (at least partly) relies on the observation that hiccups decreases as Pco2 rises. Many of the home remedies either stimulate the nasopharynx or interrupt the normal respiratory cycle: holding one's breath, being frightened (gasping), swallowing sugar and sipping ice water. Drinking from the far side of a glass is one home remedy that is probably interesting to watch even it doesn't happen to work. We have also found that drinking a glass of water through a paper towel may be effective.

When you are seeing a patient with severe hiccups or (more commonly) when you or someone you know needs relief from hiccups, there are many (mostly anecdotal) effective methods you can try. And, for an interesting piece of trivia to impress the next harbinger of hiccups you meet, the medical term for hiccups is singultus.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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