Hiccups – and the comic ‘remedies’ associated with them – are often a cause of general amusement and jokes. But how would you feel if one day you started hiccupping… and just couldn’t stop?
This is what happened to 63-year-old Frankie Thrasher, who has been hiccupping on and off for the past five years, despite trying endless traditional tips such as holding his breath, different medications and even surgery.
‘At one point I hiccupped non-stop for a full week,’ recalls Frankie, who is married to Teina, 49, a nurse.
At its worst, the problem was ‘ruining my life – I was at my wits’ end’, he says.
His hiccups started ‘randomly – there was no obvious cause and they just got worse over time’.
‘Soon I was hiccupping for two to three hours at a time. Most of the time they’d last two to three days,’ says Frankie.
At first it was simply annoying – but soon it began to dominate his life.
Now he says: ‘At their worst, I spit up white foam, gag and have episodes where I lose my breath. When this occurs I feel like I am dying.
Frankie Thrasher has been hiccupping on and off for the past five years despite trying endless traditional tips such as holding his breath, different medications and even surgery
‘It’s near-impossible to make future plans as they are decided on whether or not I have hiccups that day. I avoid outings and physical activity that may cause strain, for fear that they will return or worsen.
‘They also affect my sleep – it’s impossible to rest while having hiccups.’
To begin with Frankie – an army veteran who lives in Kentucky, US – wondered if it was food-related, so he avoided spicy foods – but this made no difference.
Two months after his hiccups first started he saw his doctor, who diagnosed ‘intractable’ (i.e. chronic) hiccups, the medical term for hiccups lasting more than a month.
Hiccups result from sudden involuntary contractions of the diaphragm (the dome-shaped muscle separating the chest and abdominal cavities) that controls breathing. This spasm, or twitch, causes a sudden intake of air and the vocal cords to snap shut, producing the hallmark ‘hic’ sound.
Fortunately, the vast majority of hiccupping fits are short-lived, resolving by themselves. Acute cases may last minutes, but in rare cases can continue for more than 48 hours.
Persistent hiccups can go on for longer, but rarely last more than a month.
However, intractable hiccups – such as Frankie’s – continue for longer and may indicate underlying issues, as we will see.
Last month it was reported that A&E departments were ‘under siege’ from patients with hiccups, sniffles and other problems that could have been dealt with elsewhere.
In many cases of temporary hiccups, spasms are trigged by eating or drinking too quickly – or too much – which causes bloating, in turn irritating the nerves surrounding your diaphragm.
Eating spicy foods, drinking alcohol and swallowing air – for instance, during laughing fits or when drinking fizzy drinks or chewing gum – can have the same effect.
A CT scan of the chest of a 50-year-old patient with a hiatus hernia. Here, the upper part of the stomach bulges through a hole in the diaphragm
Dr Hal Brindley recommends home remedies – including holding your breath and breathing into a paper bag – to treat hiccups
And there is some scientific basis for some home remedies, says Dr Hal Brindley, a gastroenterologist at HCA London Bridge Hospital.
‘Many home remedies including holding your breath, breathing into a paper bag or sipping iced water actually work – either by increasing the amount of carbon dioxide in your blood [which forces the body to resume normal breathing patterns], or by stimulating the vagus nerve [the main nerve in the body, which runs from the head to the abdomen, which serves the diaphragm] – these essentially reset the hiccup reflex,’ he explains.
But chronic hiccups are another story. They are more common in men – who make up 82 per cent of chronic cases – than women, though it’s not clear why, says Dr Brindley.
One theory is that men’s nerve circuits (including the vagus and phrenic nerves – the main nerve that controls the diaphragm) may be more sensitive. Another factor may be height: ‘Being tall or having a lower body weight has been associated with a higher risk as they are associated with anatomical arrangements of organs in relation to the phrenic and vagus nerve [that] are more likely to cause irritation or compression,’ he explains.
Certain medications can trigger longer-lasting hiccups – known medically as singultus – too, says Dr Brindley. These include steroid medication (such as dexamethasone, commonly used alongside chemotherapy in cancer patients), some anxiety drugs (such as diazepam), chemotherapy treatments (such as cisplatin) and nicotine.
‘Steroids and anxiety medications typically work by lowering the brain’s “trigger threshold”, which makes your central nervous system much more sensitive and prone to starting a hiccup spasm,’ says Dr Brindley.
‘Chemotherapy drugs and nicotine act as powerful irritants that release chemicals such as serotonin and dopamine, over-stimulating the major nerves that control your diaphragm and stomach, triggering longer-lasting hiccupping episodes,’ he adds.
However, chronic hiccups are usually related to an anatomical problem or underlying cause, says Dr Brindley – ‘which is why if your hiccups last more than 48 hours or keep coming back you, should seek medical advice’.
He adds: ‘Hiccups that continue while you are asleep often suggests a physical cause rather than a psychological one.’
Perhaps the most common of these is hiatus hernia – where the upper part of the stomach bulges through a hole in the diaphragm. Treatment depends on the size and location, and can include minimally invasive surgery to repair the tear.
However, damage from tumours and cysts can also provoke spasms in the diaphragm – and nervous system problems such as stroke or Parkinson’s disease may also disrupt diaphragm control, leading to prolonged hiccups.
Additionally, conditions that disrupt body chemistry – such as kidney disease, alcohol misuse or thyroid problems – can also contribute. By disrupting the chemical balance in the brain, they make the diaphragm more likely to spasm involuntarily.
Frankie has been prescribed an array of drugs, including epilepsy drug Neurontin
‘Because the root cause is the body chemistry itself, these hiccups are often persistent and typically only stop once the toxins are cleared – for instance, through medical treatments such as dialysis [in the case of kidney problems],’ says Dr Brindley.
Longer-term hiccups can also be caused by gastro-oesophageal reflux disease (GORD), where stomach acid flows back up into the oesophagus, irritating the vagus and phrenic nerves, which in turn causes an involuntary spasm and hiccupping.
Over time, repeated reflux in this way can cause a cycle: spasms worsen reflux by disrupting normal movement in the oesophagus, which in turn leads to more irritation and persistent hiccups.
Over-the-counter antacid medications such as Rennie can help to neutralise stomach acid, and proton pump inhibitors (PPIs) provide longer-term relief by reducing the amount of stomach acid.
Lifestyle changes – eating smaller meals, avoiding trigger foods such as spicy dishes and sleeping with your head propped up – can help with hiccups related to acid reflux.
Surgery is considered a last resort for people with intractable hiccups that haven’t responded to medication and which are causing severe exhaustion, weight loss or depression, says Dr Brindley.
‘The most common intervention is a phrenic nerve block, where an anaesthetic is injected near the nerve in the neck to stop it from sending spasm signals to the diaphragm.
‘Doctors may also occasionally use vagus nerve stimulation, where a battery-operated device is implanted to send electrical pulses to the vagus nerve in a bid to disrupt the hiccupping process.’
However, surgery doesn’t always work and carries risks: for example, phrenic nerve procedures can cause temporary or permanent paralysis of the diaphragm, which can make it difficult to breathe, especially for people with existing lung conditions.
Other risks include vocal-cord paralysis (which causes hoarseness and swallowing issues) and, in very rare cases of nerve-cutting surgery, a risk of death, says Dr Brindley.
In Frankie’s case, after researching extensively online and joining a number of support groups, he tried all the lifestyle remedies he came across – including rapidly swallowing water. He also tried acupuncture and drinking through a specially designed straw he’d read about online. None worked.
He was prescribed thorazine, a strong anti-psychotic medication that is also used to treat intractable hiccups (by intercepting the dopamine receptors in the brain and interrupting the ‘hiccup arc’); Neurontin (gabapentin, an anticonvulsant drug used for epilepsy that can sometimes help manage hiccups by calming nerve activity); Reglan (metoclopramide, a medication for heartburn and reflux), baclofen (an anti-spasmodic) and Pepcid (famotidine, which reduces stomach acid production and reflux).
‘Nothing worked,’ says Frankie.
Finally, last June he was referred for surgery to repair a hiatus hernia, which his doctor believed might be worsening the hiccups.
‘But within days of the surgery I was hiccupping non-stop again,’ recalls Frankie.
Now phrenic nerve surgery is his only hope – and he is awaiting referral for a potential phrenic nerve block.
‘When my hiccups are at their worst I don’t want to be left alone, fearing that if I stop breathing there will be no one to call for help,’ he says.
‘I typically try to keep a positive outlook but there have been times when I have wanted to give up or have felt hopeless. I hope one day there’ll be a cure.’
