Long-term hiccups have been a plague

Dear Dr. Roach: My friend has been struggling with almost never-ending hiccups since she was young. There seems to be no apparent trigger. They happen all hours of the day and even wake her up. She will hiccup until it starts to become painful for her, and she cannot make them stop. She’s tried every remedy she can find.

She lives in a rural community with no doctor who can figure it out. They also don’t seem to take seriously how disruptive and painful it is. They tell her there’s nothing they can do. Do you have any suggestions? — N.E.

Persistent hiccups can be a severe problem. The hiccup is a spasm of the diaphragm, the main muscle of breathing, and an ancient neurological reflex. There are numerous case reports of people having hiccups lasting for decades. The effect on a person’s quality of life can be devastating.

In a person with hiccups lasting more than 48 hours, it’s appropriate to look for one of the more common causes, but often, a cause is not found. This starts with a careful history and physical examination. A history of medication use is critical, since some medicines are known causes.

Enlarged thyroid and enlarged lymph nodes are causes of irritation to the phrenic nerve. Oddly, irritation in the external ear can stimulate the vagus nerve, so inspection of the ear is indicated as well. Gastroesophageal reflux disease may be the most common cause and it sometimes can be seen on exam, even if the person has no symptoms. A stroke is a known cause.

If no cause is found, a doctor must make his or her best guess at treatment. The most common drugs tried are gabapentin, baclofen, metoclopramide and chlorpromazine, but only the last of these is indicated by the Food and Drug Administration for hiccups. None of these drugs is benign enough to use lightly.