February 27, 2013
By Robert H. Shmerling M.D.
Beth Israel Deaconess Medical Center
Last reviewed and revised February 27, 2013
How many times have you seen this in the movies and on television: The "drunk," slumped on his barstool, is telling his sad tale to the bartender or anyone else willing to listen. And every other word is punctuated with an involuntary spasm of the shoulders and a short, squeaking noise — a hiccup.
Ever wonder why we get the hiccups? Are they really associated with alcohol use? And to get rid of them, does frightening the "hiccupper" really work?
Hiccups in Health
The reason we hiccup is unknown. The phenomenon is nearly universal and it can even be observed in a fetus, especially during the last trimester of pregnancy. The technical term for hiccups is singultus (from the Latin, singult, which describes catching your breath while crying). Hiccupping is a complex reflex: A sudden contraction or spasm of the diaphragm and the muscles between the ribs makes you inhale quickly and involuntarily. It ends with "glottic closure" — the space in the throat near the vocal cords snaps shut, producing the typical sound. In most cases, only one of the two sides of the diaphragm is involved; it is left-sided in 80% of cases.
While much is uncertain, this much is clear: Most of the time hiccups are simply a normal part of the human condition and, as annoying as they may be, they rarely last long. While hiccups occasionally indicate illness (as described below), they rarely are cause to worry, and there should be no urgency to "cure" yourself when the hiccups will almost always go away soon regardless of what you do.
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Most likely hiccups are a reflex. Nerves inside the chest send signals to the diaphragm and muscles between the ribs to spontaneously contract during normal breathing. This "hiccup reflex" may be set off by many triggers, including:
- Emotional stress or excitement
- Stretching of the stomach, as may occur after overeating, drinking carbonated beverages, or swallowing air
- Abrupt changes in the temperature (as with drinking a hot beverage)
- Alcohol binging
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What Is Normal?
It is not easy to define "normal" hiccups. My medical dictionary describes them as "a spasmodic inhalation with closure of the glottis accompanied by a peculiar sound" — fair enough! But what if it goes on for an hour or more? At some point, everyone might agree that prolonged or particularly forceful or painful hiccups are not normal and warrant more than the usual "wait it out" strategy. Experts have set up these definitions for hiccups based on how long they last:
- A bout of hiccups — Having hiccups on and off for up to 48 hours
- Persistent hiccups — Hiccups that last more than 48 hours but less than one month
- Intractable hiccups — Hiccups lasting two months or more
A standard definition of "abnormal" hiccups is important in order to study the phenomenon in illness and to determine effective treatment.
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Hiccups in Disease
Although it is rare, intractable hiccups may be a sign of disease and cause problems of their own, such as difficulty eating, weight loss, dehydration and poor sleep. There are even very rare reports of hiccups contributing to death. The most famous is that of Pope Pius XII in 1958 whose death was widely reported to be related to intractable hiccups. However, he apparently suffered from recurrent gastritis, which itself could have provoked persistent or intractable hiccups, and he ultimately died of strokes and pneumonia. The world record for hiccups (according to Guinness) is held by a farmer from Iowa who apparently hiccupped for more than 60 years for no known reason. When hiccups develop after major surgery, each hiccup may cause significant pain and can impair wound healing.
When hiccups are associated with medical problems, the cause is usually irritation of one of the nerves in the chest. Examples include laryngitis, goiters (enlargement of the thyroid gland), tumors in the neck, infections near the diaphragm, and hiatal hernia (usually with gastroesophageal reflux disease, or GERD). Hiccups can also be triggered by excess alcohol use, kidney failure and other infections (especially ear infections). Rarer causes are aortic aneurysms and multiple sclerosis.
Treating a disorder that may be triggering hiccups is usually the first course of action for prolonged or intractable hiccups. For example, surgical removal of a tumor, medication treatment for GERD (such as cimetidine or omeprazole) or antibiotic treatment of an infection may reduce or even eliminate severe hiccups when one of those conditions is the trigger.
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Myth or Not?
Although there is much we do not understand about hiccups and how to make them stop, this much seems to be true:
- Hiccups are not a reliable sign of alcohol use.
- Holding one's breath, breathing into a bag, being frightened, swallowing sugar or drinking from the opposite side of a glass may be effective (though scientific proof is lacking). Other maneuvers that may work (and seem reasonably safe) include biting on a lemon, pulling on the tongue, gargling ice water or "tickling" the hard palate with a cotton swab. Knowing just how effective each of these may be and how much is myth is difficult because they are advocated primarily for "benign" hiccups that would likely resolve on their own regardless of treatment.
- Medications can reduce hiccups. Among those with scientific evidence of effectiveness are chlorpromazine, metoclopramide and baclofen (although side effects may be limiting). A variety of other medications have been suggested, though unproven. These include anticonvulsants (such as phenytoin), antidepressants (such as amitriptyline) and even marijuana.
- Certain drugs are thought to cause hiccups. Discontinuing these medicines can an effective cure. Examples include midazolam (a relative of Valium), some types of chemotherapy, and digoxin (a heart medication).
- Other approaches with rare reports of effectiveness for intractable hiccups include hypnosis, acupuncture and even surgery. Two examples of surgical procedures are a "nerve block" that stops the phrenic nerve (the major nerve supply for the diaphragm) from sending signals so that the diaphragm stops contracting, and implantation of a pacemaker that results in more rhythmic contractions of the diaphragm.
- Hiccups may be dangerous, but that's rare. As mentioned above, weight loss, poor wound healing and even death occasionally have been attributed to hiccups.
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The Bottom Line
Hiccups are a normal and common human experience (though shared by many animals as well). They may serve an important purpose, although what that could be remains unknown. The next time you are afflicted with hiccups and everyone around you is giving you different advice, you may be better off politely walking away; chances are excellent that your hiccups will soon pass no matter what you do. And while others may think you've been drinking just because you have the hiccups, let them know that's a common misconception — unless, of course, it's true.
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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.
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