A hiccup is a sudden, involuntary movement (spasm) of the diaphragm muscle. The diaphragm is the thin layer of muscle that separates the chest from the abdomen and plays an important role in breathing. When this muscle spasms, the vocal cords snap shut. The glottis shuts off the windpipe and the hiccup sound (the classic “hic”) is produced. Contraction of the diaphragm is usually unilateral, occurring only on the left side of the body. It may repeat several times per minute. Hiccups are myoclonic jerks where brief, involuntary twitches occur to a muscle or a group of muscles. They belong to the positive myoclonus subcategory.
What is a Hiccup?
In medicine, hiccups are called synchronous diaphragmatic flutter (SDF), or singultus. This is the Latin word for catching one’s breath while sobbing. Hiccups are forms of reflex actions. A reflex action is the immediate withdrawal of an organ from dangerous stimuli. A reflex arc is a neural pathway that facilitates such fast, automatic response.
Hiccups either occur individually or in a constant rhythm. They are usually resolved on their own without intervention. Due to its temporary annoying state, home remedies are sought to cure or shorten the period of a hiccup. In case of chronic hiccups, medical treatment is necessary.
Hiccups in Folklore:
In folklore, hiccups have different significances and there are many myths behind them. In the Slavic and Balkan folklore, hiccups are said to occur to somebody when people are talking about him/her behind his/her back. However, according to Arabic, Indian and Nepalese folklore, a person hiccups when someone is thinking about him/her at that moment.
Superstitious people in the pre-Renaissance Europe believed that a person who had hiccups was possessed by the devil and his/her body was giving him/her a signal that bad luck was on the way, especially if the hiccups lasted for a few days. They even went as far as believing that horseshoes (the universal good luck charms) gained their reputation for their ability to cure hiccups.
Hiccups: Another Evolutionary Process?
Interestingly, scientists believe that hiccups are evolutionary processes. They go as far as when our ancestors possessed gills to help them breathe under the sea. Those primitive air breathers would push water across their gills, squeeze their mouth cavities and close the glottis to prevent water from entering their lungs, resulting in the hiccup. Some scientists have provided two theories to explain why babies hiccup in their mothers’ wombs. Firstly, the contractions would prepare the unborn baby’s respiratory muscles for breathing after birth. Secondly, the baby would be keeping the amniotic fluid out of the lungs.
Some scientists believe that this seemingly random habit passed on with evolution to help mammals suckle, so that milk won’t enter the baby’s lungs during the breastfeeding process.
Types of Hiccups:
There are three types of hiccups. Each one has its own predisposing factors, causes and duration. A hiccup bout is the short-term one. It lasts from several seconds to several days. A persistent hiccup lasts for several days or weeks. Intractable hiccups last for more than a month and in rare cases, they may continue for years.
Causes of Hiccups:
Apart from evolutionary studies, the obvious cause is practically unknown. However, there are a few common causes for why we get hiccups:
- Eating too fast and swallowing air with food.
- Eating or drinking too much.
- Fatty foods, spicy foods and soda drinks.
- Drinking alcohol.
- Drinking a hot drink followed by a cold drink which cause a sudden change in the stomach temperature.
- Abdominal surgery: This irritates the nerves that control the diaphragm causing hiccups.
- Diseases or disorders that irritate the nerves that control the diaphragm such as liver disease, pneumonia, GERD, strokes, brain tumors, Neuromyelitis optica (a central nervous system (CNS) disease affecting the optic nerves and spinal cord due to myelin loss) and kidney failure.
- Chewing gum and swallowing air in the process.
- Intense emotions such as stress, fear or excitement.
- Noxious fumes.
- Sudden change in room temperature.
- Some medications cause hiccupping as a side effect:
- Acid reflux medications: Omeprazole, dexlansoprazole and metoclopramide.
- Most benzodiazepines: Diazepam, alprazolam and lorazepam.
- Levodopa, nicotine, and ondansetron.
In case of persistent and intractable hiccups, causes may be more serious. They vary between:
- Central nervous system diseases and disorders such as stroke, infections, cancer or injury.
- Metabolic functions such as decreased kidney functions or hyperventilation.
- Irritation of the vagus and phrenic nerves in the head, neck or chest.
- Mental health problems, anesthesia or surgery.
How to Diagnose a Hiccup:
Hiccups are usually resolved on their own. Diagnosis is only a must in case of a hiccup that persists for more than 3 hours, if they frequently come back, if they affect sleeping, if it occurs with severe abdominal pain or if you spit up blood. In that case, the diagnosis starts with the GP examining the patient’s head and neck (including mouth), chest and abdomen. A series of tests are recommended by the physician to check for underlying causes to the hiccup including:
- Blood tests to check for diabetes, kidney or liver failure.
- X-ray, CT scan or MRI scan to check for tumors or an infection.
- An electrocardiogram (ECG) to check for heart conditions.
- Endoscopy is recommended in case of GERD disease to examine the patient’s oesophagus and stomach.
Signs and Symptoms of Hiccups:
Signs and symptoms vary according to the type of the hiccup produced. A hiccup could be a single or a series of diaphragm contractions, varying in space or duration. It might also be a brief and unexpected shoulder, throat, abdomen or full body tremor. It might be presented as an audible chirp (squeak), a quick inhaling gasp, sigh or sniff. Finally a hiccup might be in a more severe form of distracting, occasional interruptions in normal breathing with sudden momentary pain of the throat, chest or abdomen.
How to Get Rid of Hiccups:
Folk and Home Remedies:
Getting rid of hiccups seems to be the ultimate goal in terms of dealing with it. Even in case of hiccup bouts, which take no more than 3 minutes to be resolved on its own, people still aim to shorten its duration. A hiccup causes embarrassment, annoyance, social insecurity, speech and sleep impairment. Getting rid of the hiccup involves various methods from home remedies to breathing exercises and in case of a persistent hiccup, medications are introduced.
There are millions of home remedies for treating short-term hiccups. Among the most common are the following:
- Head standing.
- Drinking nine gulps of water while holding your breath.
- Swallowing a teaspoon of sugar (this could be explained in terms of counteracting a reflex action with another reflex action. In that case it would be increased salivation due to the salivary glands being stimulated by sugar in the mouth).
- Swallowing a spoonful of peanut butter or honey.
- Gargling with ice water (without swallowing the ice).
- Having a person breathe into a paper bag or hold their breath (This increases the partial pressure of carbon dioxide, inhibiting diaphragm activity).
- Drinking a glass of water upside-down.
- Scaring the person hiccupping.
- Swallowing crushed ice (Iced gastric lavage) or swallowing dry bread (irritating the pharynx and thus stimulating the vagus nerve).
- Stimulating the gag reflex.
- Biting on a lemon.
- Valsalva maneuver (which is a method of trying to exhale with force with the windpipes closed, as if blowing up a balloon).
- Tasting vinegar or in some cases swallowing a teaspoonful of it (mixed with sugar to break the sourness of the taste).
- Using smelling salts.
- Provoking sneezing.
- Applying pressure to the tongue.
- Tickling the palate with a swab (uvular stimulation).
- Dermatome stimulation by tapping or rubbing the neck.
- Distracting the person hiccupping (some word games or memory exercises could be used).
- Pulling your knees up or leaning forward to compress your chest.
- Putting a finger in your ear (another distracting method).
Fast Methods to Get Rid of Hiccups:
Many people with hiccup bouts tend to look for ways to get rid of hiccups as fast as possible. When in an important meeting or before giving a speech, people tend to look for the most effective and rapid ways to eliminate hiccups. Many folk remedies suggest digging into controlling your breathing either by slowing it down, breathing in and swallowing at the same time, swallowing open-mouthed with continuous gulping and to imagine breathing in a figure eight. Other methods to stop hiccups within a few seconds include: stretching your diaphragm, using your tongue and ears to push air out of your body.
Medical Treatment for Hiccups:
Using home remedies might be enough to stop short-term hiccups. In case of persistent or intractable hiccups, medications are used to manage the patient’s hiccup.
Therapy regimen for the hiccup follows a certain sequence. At first, the underlying cause of the hiccup is treated (if present) then the physician aims to cure the hiccup itself (if necessary). Treatment may be pharmacologic or non-pharmacologic. However, hiccup treatment has no guidelines in the medical textbooks because until now no treatment has proven valid and effective for persistent or intractable hiccups. Mostly treatment is case-specific. Even the most definitive cure for hiccups would not be the optimal therapy in some cases.
Among the most effective antipsychotic agents used to treat intractable hiccups are chlorpromazine and haloperidol. Chlorpromazine, in particular, seems to be the drug of choice when given intravenously. However, since hypotension is a severe side effect of this antipsychotic, 500-1000 mL of IV fluid preload should be administered to the patient.
Metoclopramide, an antiemetic and stomach stimulant, is second-best in treating intractable hiccups. It is also the safest drug used for treatment due to its lack of serious side effects.
Ketamine, an anesthetic, is used but in a dose one fifth of its anesthetic potency.
Several anticonvulsant agents are used to treat intractable hiccups such as phenytoin, valproic acid, and carbamazepine. Baclofen, gabapentin, amantadine, nifedipine, amphetamine and various proton-pump inhibitors are also used.
Non-pharmacologic treatment includes many invasive and highly critical procedures. They have many approaches and methods. Some remedies aim at opposing the reflex action. Others are mainly concerned with vagal stimulation. Some physicians suggest meditation and acupuncture as way to get rid of hiccups.
In certain cases, hiccups were terminated by direct traditional acupuncture. A needle is inserted at a specific interspinal space between the 7th cervical vertebra and the 1st thoracic vertebra. The needle is manipulated until a de-qi sensation (numbness and tingling) is achieved. The process is continued for 10 minutes until the patient releases a long sigh with which both the de-qi sensation and the hiccup subside. The acupuncturist takes out the needle 15 minutes after hiccups cease.
Surgical intervention could be sought in case of highly intractable hiccups. It is usually the last resort and the final treatment step. Phrenic nerve ablation (unilateral or bilateral ablation, although the latter results in serious respiratory complications) and microvascular decompression of the vagus nerve are among the most successful medical interventions.
Baby Hiccups: Dos and Don’ts:
In case of babies, hiccups are even more annoying than in adults. A baby doesn’t understand what is happening and hiccups make for a great deal of annoyance. It is rare, however, that hiccups stray from normal, as all babies get them one time or another. Hiccups treatment in babies mainly focuses on home remedies and folk recipes. However, not all folk remedies are valid in case of babies. Scaring is unadvisable because it results in traumatic conditions for the baby. Giving the baby gripe water helps a lot, also breastfeeding. Some physicians suggest rocking the baby while rubbing its back in an upwards, waist to shoulders, motion. Also if the baby gets the hiccups after eating, keeping it upright for 30 minutes would definitely help get rid of the hiccup. Some people are also skeptical at most remedies for baby hiccups. They say it is safer to let the hiccup resolve on its own.
Hiccups in Other Mammals “a.k.a. Thumps”:
Apart from humans, hiccups occur in horses as well. They are called “thumps”. Thumps in and of itself is not a problem but it usually occurs due to an underlying medical condition. It is common in equine athletes –especially the Arabian horse breed- where competing in long distance races causes electrolyte imbalance and significant fluid loss. Clinical signs of thumps include sounds coming from the horse’s abdomen in addition to the latter’s contracting with the animal’s heartbeat. Thumps generate an alarming symptom in horses, unlike in humans because it is most certainly due to an underlying dehydration.