Children

• Seek specialist advice if drug treatment is being considered for a child.

Adults

• If a person has symptoms suggestive of gastro-oesophageal reflux and has no upper gastrointestinal alarm symptoms, consider a trial course of a proton pump inhibitor (see the CKS topic on Dyspepsia - unidentified cause).
• For symptom relief, consider the following drugs in primary care (taking into account the licensed indication and the number of case reports of effectiveness):
• Chlorpromazine (licensed) — avoid in a palliative care situation because of its potential adverse effects.
• Haloperidol (licensed).
• Baclofen (off-licence indication) — may be particularly useful when other drugs have failed.
• Metoclopramide (off-licence indication) — may be particularly useful for people with hiccups due to gastric stasis or distension.
• Gabapentin (off-licence indication) — may be effective if the hiccups have a neurological cause. Use with caution in people with renal impairment and the elderly.
• Midazolam (off–licence indication) — consider only on specialist advice in the terminal phase of advanced cancer if the person is very distressed by the hiccups.
• Suggested dosages for use in primary care are outlined in Table 1. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk) or the British National Formulary (BNF) (www.bnf.org).
• Try a drug for 2 weeks, increasing the dosage until hiccups are controlled, until adverse effects prove troublesome, or until the maximum recommended dosage is reached.
• If this is effective, try reducing the dose and stopping the drug. If hiccups recur, increase the dose again or restart the drug if it was stopped.
• If the drug is not effective or is not tolerated, consider trying a different drug while awaiting referral.