Almost all of us have had a case of hiccups. Typically, they are annoying, embarrassing, and cause us mild frustration. We hold our breath, try eating some peanut butter or ask a friend to scare us. The nuisance passes, and we resume our daily routine. However, this rudimentary body function can impact our quality of life when it becomes chronic. They can disrupt sleep, interfere with conversation and concentration, and even cause pain if they persist long enough.
Where do Hiccups Come From?
Hiccups stem from stimulation of the phrenic and vagus nerves, as well as involvement from the central reflex center in the brainstem. They can have multiple causes, including stress, excitement, cancer, recent heart attack, dilation of the stomach or esophagus, liver problems, kidney problems, central nervous system disease, or medications, such as chemotherapy and steroids. They can also be idiopathic, therefore identifying the underlying cause may help focus treatment. Multiple approaches to hiccup treatment exist, including nonpharmacologic alternatives. However, there is little evidence that any treatment is more beneficial than another.
Nonpharmacologic treatments include swallowing sugar, gargling with water, biting a lemon, or trying to induce a fright response. One can attempt to interrupt the normal breathing routine by holding one’s breath or hyperventilating. Those with medical knowledge can attempt vagal nerve stimulation via carotid massage or interruption of phrenic nerve transmission by rubbing over the 5th cervical vertebrae.
Multiple medication classes may provide a worthy treatment. These include the older antipsychotics; such as haloperidol and chlorpromazine. Some anticonvulsants may also be effective, including gabapentin, phenytoin, and valproic acid. A muscle relaxant, baclofen, can also be helpful.
For those cases where typical non-pharmacologic methods and multiple pharmacologic therapies fail, more aggressive options do exist. These include the placement of diaphragmatic pacing electrodes or surgical ablation of the nerve reflex arc.
When developing a treatment protocol, it is essential to consider a patient’s prognosis, comorbidities, and potential treatment side effects. Hospice patients tend to, on average, have a shortened prognosis, multiple comorbidities, and can be more sensitive to medication untoward effects. We must also weigh the burden that the hiccups are causing to the patient enjoying their life. Quality of life is always our utmost goal. Hiccups are not one of the most common symptoms we deal with in hospice care, but they can be one of the most distressing and challenging to treat. As always, if you or a loved one are touched by a terminal illness, please reach out to Hospice of Southern Illinois to ease the journey.