Hiccup

A hiccup (scientific name singultus, from a Latin word meaning "to catch one's breath while sobbing";[1] also spelled hiccough) is an involuntary contraction (myoclonic jerk) of the diaphragm that may repeat several times per minute. The hiccup is an involuntary action involving a reflex arc.[2] Once triggered, the reflex causes a strong contraction of the diaphragm followed about a quarter of a second later by closure of the vocal cords, which results in the "hic" sound.

Hiccup
Other namesSingultus, hiccough, synchronous diaphragmatic flutter (SDF)
Pronunciation
  • /ˈhɪkəp, -ʌp/ HIK-əp, -⁠up
SpecialtyOtorhinolaryngology

Hiccups may occur individually, or they may occur in bouts. The rhythm of the hiccup, or the time between hiccups, tends to be relatively constant. A bout of hiccups generally resolves itself without intervention, although many home remedies are often used to attempt to shorten the duration.[3] Medical treatment is occasionally necessary in cases of chronic hiccups.

Incidence

Hiccups affect people of all ages, even being observed in utero. They become less frequent with advancing age. Intractable hiccups, lasting more than a month, are more common in adults. While males and females are affected equally often, men are more likely to develop hiccups lasting more than 48 hours.[1] Dogs may also get hiccups.[4]

Signs and symptoms
Histogram of period (in seconds) between each hiccup in a sequence of 50 samples in about 10 minutes. Mean: 11.40 s. Median: 10.715 s. Standard deviation: 2.88 s. Data set ranges from 6.28 s to 21.36 s.

A hiccup consists of a single or a series of breathing diaphragm spasms, of variable spacing and duration, and a brief (less than one half second), unexpected, shoulder, abdomen, throat, or full body tremor. Hiccups may present as an audible chirp, squeak, "hupp", or if controlled, a quick inhaling gasp, sigh, or sniff. They may also present as brief but distracting or painful interruptions in normal breathing, with sudden momentary pain of the throat, chest, or abdomen.

Causes

Pathophysiological causes

Hiccups may be triggered by a number of common human conditions. In rare cases, they can be a sign of serious medical problems. In rare cases, hiccups can be the sole symptom of myocardial infarction.[12]

Pre-phrenic nucleus irritation of medulla

CNS disorders

Nerve damage

Other known associations
  • Although no clear pathophysiological mechanism has been described, hiccups is known to have been the initial symptom of Plasmodium vivax malaria in at least one documented case.[15]

Phylogenetic hypothesis

An international respiratory research group composed of members from Canada, France, and Japan proposed that the hiccup is an evolutionary remnant of earlier amphibian respiration.[16] Amphibians such as tadpoles gulp air and water across their gills via a rather simple motor reflex akin to mammalian hiccuping. The motor pathways that enable hiccuping form early during fetal development, before the motor pathways that enable normal lung ventilation form. Thus, the hiccup is evolutionarily antecedent to modern lung respiration.

Additionally, this group (C. Straus et al.) points out that hiccups and amphibian gulping are inhibited by elevated CO2 and may be stopped by GABAB receptor agonists, illustrating a possible shared physiology and evolutionary heritage. These proposals may explain why premature infants spend 2.5% of their time hiccuping, possibly gulping like amphibians, as their lungs are not yet fully formed.[17]

The phylogenetic hypothesis may explain hiccups as an evolutionary remnant, held over from our amphibious ancestors.[18] This hypothesis has been questioned because of the complexity of the mammalian hiccup reflex compared to the amphibian breathing reflex, the fact that it does not explain the reason for glottic closure, and because the very short contraction of the hiccup is unlikely to have a significant strengthening effect on the slow-twitch muscles of respiration.

Fetal intrauterine hiccups are of two types. The physiological type occurs prior to twenty-eight weeks after conception and tends to last five to ten minutes. These hiccups are part of fetal development and are associated with the myelination of the phrenic nerve, which primarily controls the thoracic diaphragm.

The phylogenetic and the burping hypotheses are not mutually exclusive. The phylogeny hypothesis could explain how the hiccup reflex might have evolved, while the "Burping Hypothesis" could explain why it would offer enough of an evolutionary advantage to persist and increase in complexity.

Duration

Episodes of hiccups usually last just a few minutes, doing nothing worse than annoying those affected and amusing bystanders, but prolonged attacks can be serious, with a cause difficult to diagnose. Such attacks can cause significant morbidity and even death.[1] An episode lasting more than a few minutes is termed a bout; a bout of over 48 hours is termed persistent or protracted. Hiccups lasting longer than a month are termed intractable. In many cases, only a single hemidiaphragm, usually the left one, is affected, although both may be involved.[1]

Treatment

Hiccups are normally waited out, as any fit of them will usually pass quickly. Folk 'cures' for hiccups are common and varied, but no effective standard for stopping hiccups has been documented. Hiccups are treated medically only in severe and persistent (termed "intractable") cases.

Numerous medical remedies exist but no particular treatment is known to be especially effective, generally because of a lack of high-quality evidence.[19][20] Many drugs have been used, such as baclofen, chlorpromazine, metoclopramide, gabapentin, and various proton-pump inhibitors. Hiccups that are secondary to some other cause, like gastroesophageal reflux disease or esophageal webs, are dealt with by treating the underlying disorder. The phrenic nerve can be blocked temporarily with injection of 0.5% procaine, or permanently with bilateral phrenicotomy or other forms of surgical destruction. Even this rather drastic treatment does not cure some cases, however.

Haloperidol, metoclopramide, and chlorpromazine are used in cases of intractable hiccups. Effective treatment with sedatives often requires a dose that renders the person either unconscious or highly lethargic. Hence, medicating with sedatives is only appropriate short-term, as the affected individual cannot continue with normal life activities while under their effect.

A vagus nerve stimulator has been used with an intractable case of hiccups. "It sends rhythmic bursts of electricity to the brain by way of the vagus nerve, which passes through the neck. The Food and Drug Administration approved the vagus nerve stimulator in 1997 as a way to control seizures in some patients with epilepsy."[21]

Persistent digital rectal massage has also been proven effective in terminating intractable hiccups.[22]

Folk remedies

There are many superstitious and folk remedies for hiccups, including headstanding, drinking a glass of water upside-down, being frightened by someone, breathing into a bag, eating a large spoonful of peanut butter and placing sugar on or under the tongue.[23][24]

Acupressure, either through actual function or placebo effect, may cure hiccups in some people. For example, one technique is to relax the chest and shoulders and find the deepest points of the indentations directly below the protrusions of the collarbones. The index or middle fingers are inserted into the indents and pressed firmly for sixty seconds as long, deep breaths are taken.[25]

A simple treatment involves increasing the partial pressure of CO2 and inhibiting diaphragm activity by holding one's breath or rebreathing into a paper bag.[26] Other potential remedies suggested by NHS Choices include pulling the knees up to the chest and leaning forward, sipping ice-cold water and swallowing some granulated sugar.[27]

Drinking through a straw with the ears plugged is a folk remedy that can be successful.[28] In 2021 a scientific tool with a similar basis was tested on 249 hiccups subjects; the results were published in the Journal of the American Medical Association (JAMA).[29][28] This device is named FISST (Forced Inspiratory Suction and Swallow Tool) and branded as "HiccAway". This study supports the use of FISST as an option to stop transient hiccups, with more than 90% of participants reporting better results than home remedies. HiccAway stops hiccups by forceful suction that is being generated by diaphragm contraction (phrenic nerve activity), followed by swallowing the water, which requires epiglottis closure.[30]

Society and culture

The word hiccup itself was created through imitation. The alternative spelling of hiccough results from the association with the word cough.[31]

  • American Charles Osborne (December 14, 1892 – May 1, 1991) had hiccups for 68 years, from 1922 to February 1990,[32] and was entered in the Guinness World Records as the man with the longest attack of hiccups, an estimated 430 million hiccups.[33]
  • In 2007, Florida teenager Jennifer Mee gained media fame for hiccuping around 50 times per minute for more than five weeks.[34][35]
  • Christopher Sands, a Briton, hiccupped an estimated 10 million times in a 27-month period from February 2007 to May 2009. His condition, which meant that he could hardly eat or sleep, was eventually discovered to be caused by a tumor on his brain stem pushing on nerves causing him to hiccup every two seconds, 12 hours a day. His hiccups stopped in 2009 following surgery.[36]

In Baltic, German, Hungarian, Indian, Romanian, Slavic, Turkish, Greek, Albanian and among some Tribes in Kenya, for example the Luos folklore, it is said that hiccups occur when the person experiencing them is being talked about by someone not present.[37][38]

See also
  • Getting the wind knocked out of you
  • Mr. Hiccup
  • Sneeze
  • Thumps, a more serious form of hiccups found in equines
  • Yawn
  • Vocal hiccup

References
  1. Sinert, Richard H. (26 July 2021). "Fast Five Quiz: Hiccups". Medscape.
  2. Wilkes, Garry (2 August 2007). "Hiccups". eMedicine. Medscape. Retrieved 22 April 2009.
  3. "Hiccups". Home Remedies. Retrieved 5 November 2011.
  4. "Are puppy hiccups normal?".
  5. "Hiccups". WebMD. Retrieved 6 February 2014.
  6. "Gastroesophageal Reflux Disease". A.D.A.M Medical Encyclopedia. PubMed Health. Archived from the original on 4 January 2014. Retrieved 18 July 2016.
  7. Willis, FM (2003). "Chronic hiccups". Modern Drugs Discovery. 6 (6). Retrieved 12 October 2016.
  8. Howes, D. (2012). "Hiccups: A new explanation for the mysterious reflex". BioEssays. 34 (6): 451–453. doi:10.1002/bies.201100194. PMC 3504071. PMID 22377831.
  9. "Hiccups Happen!" (PDF). University of Maryland Hospital for Children. Archived from the original (PDF) on 10 January 2012. Retrieved 2 April 2012.
  10. Lauterbach, E. C. (1999). "Hiccup and apparent myoclonus after hydrocodone: review of the opiate-related hiccup and myoclonus literature". Clinical Neuropharmacology. 22 (2): 87–92. doi:10.1097/00002826-199903000-00004. PMID 10202603.
  11. Milano, Meadow. "Causes of Hiccups". Livestrong. Archived from the original on 25 November 2010. Retrieved 2 April 2012.
  12. Rueckert, Kamiar Kersten (January 2020). "Case Report: From Irregular Hiccups to Acute Myocardial Infarction" (PDF). The Permanente Journal - Kaiser Permanente. 24 (5): 1. doi:10.7812/TPP/20.180. PMC 8817908. PMID 33635776. S2CID 232066350. Archived from the original (PDF) on 14 July 2021. Retrieved 31 December 2020.
  13. "Hiccups: Causes". MayoClinic.com. 3 June 2011. Retrieved 10 July 2013.
  14. Witoonpanich R, Pirommai B, Tunlayadechanont S (2004). "Hiccups and multiple sclerosis". Journal of the Medical Association of Thailand (Chotmaihet Thangphaet). 87 (10): 1168–71. PMID 15560692.
  15. Guadarrama-Conzuelo, F; Saad Manzanera, A D (1 September 2019). "Singultus as an Unusual Debut of Plasmodium vivax Malaria". Cureus. 11 (9): e5548. doi:10.7759/cureus.5548. PMC 6820320. PMID 31695971.
  16. Straus C, Vasilakos K, Wilson RJ, Oshima T, Zelter M, Derenne JP, Similowski T, Whitelaw WA (February 2003). "A phylogenetic hypothesis for the origin of hiccough". BioEssays. 25 (2): 182–188. doi:10.1002/bies.10224. PMID 12539245. S2CID 14200209.
  17. Kahrilas, P; Shi, G. (1997). "Why do we hiccup?". Gut. 41 (5): 712–713. doi:10.1136/gut.41.5.712. PMC 1891574. PMID 9414986.
  18. "Why we hiccup". BBC News. 6 February 2003.
  19. Porter, Robert S., ed. (2011). "Hiccups". The Merck Manual Online. Merck Sharp & Dohme. Archived from the original on 14 October 2013. Retrieved 7 October 2011.
  20. Moretto, Emilia N; Wee, Bee; Wiffen, Philip J; Murchison, Andrew G (31 January 2013). "Interventions for treating persistent and intractable hiccups in adults". Cochrane Database of Systematic Reviews. 2019 (1): CD008768. doi:10.1002/14651858.cd008768.pub2. PMC 6452787. PMID 23440833.
  21. Schaffer, Amanda (10 January 2006). "A Horrific Case of Hiccups, a Novel Treatment". The New York Times. Retrieved 24 April 2008.
  22. Odeh M, Bassan H, Oliven A (February 1990). "Termination of intractable hiccups with digital rectal massage". Journal of Internal Medicine. 227 (2): 145–6. doi:10.1111/j.1365-2796.1990.tb00134.x. PMID 2299306. S2CID 20742803.
  23. Engleman EG, Lankton J, Lankton B (December 1971). "Granulated sugar as treatment for hiccups in conscious patients". The New England Journal of Medicine. 285 (26): 1489. doi:10.1056/nejm197112232852622. PMID 5122907.
  24. Boswell, Wendy (25 March 2007). "MacGyver Tip: Cure hiccups with sugar". The People's Pharmacy (Lifehacker). Retrieved 30 November 2009.
  25. Gach, Michael Reed (1990). Acupressure's Potent Points: A Guide to Self-Care for Common Ailments (1 ed.). New York: Bantam Books. p. 272. ISBN 0553349708. OCLC 1035683945.
  26. Klosowski, Thorin (30 January 2014). "The Two Mechanisms That Make Hiccup Cures Actually Work". Lifehacker Australia. Retrieved 16 September 2016.
  27. "Hiccups". NHS Choices. 15 July 2017. Retrieved 25 December 2017.
  28. Ellis, Ralph (22 June 2021). "Inventor Says His New Straw Will Cure Hiccups". Medscape.
  29. Alvarez, James; Anderson, Jane Margaret; Snyder, Patrick Larry; Mirahmadizadeh, Alireza; Godoy, Daniel Agustin; Fox, Mark; Seifi, Ali (2021). "Evaluation of the Forced Inspiratory Suction and Swallow Tool to Stop Hiccups". JAMA Network Open. 4 (6): e2113933. doi:10.1001/jamanetworkopen.2021.13933. ISSN 2574-3805. PMC 8214157. PMID 34143196.
  30. Seifi A, inventor. Hiccup relieving apparatus. US patent application publ. US 2020/0188619 A1. June 18, 2020. US20200188619A1. https://patentimages.storage.googleapis.com/c1/fa/54/c983a34c045f36/US20200188619A1.pdf
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  32. In pictures | Guinness medical record breakers | Longest attack of hiccups. BBC News. Retrieved on 2 June 2013.
  33. "Survivor of 68-Year Hiccup Spell Dies". Omaha World-Herald (Sunrise ed.). 5 May 1991. p. 2.B.
  34. "Florida girl hiccuping again after returning to school". MSNBC. 16 March 2007. Archived from the original on 18 March 2007.
  35. "'Hiccup Girl' Jennifer Mee May Use Tourette's Defense, Says Lawyer". CBS News. 27 October 2010. Archived from the original on 1 January 2011.
  36. Britten, Nick (11 January 2010). "Singer who hiccupped 20 million times in three years cured after brain tumour surgery". Archived from the original on 12 January 2022. Retrieved 13 January 2020 – via www.telegraph.co.uk.
  37. "A régi babonák napjainkban is élnek" (in Hungarian). ujszo.com. Archived from the original on 20 December 2016. Retrieved 3 December 2016.
  38. Schersch, Ursula (17 November 2010). "Schluckauf: Wer denkt an mich?". derStandard.at (in German). Retrieved 3 April 2018.

Further reading
  • Provine, Robert R. Curious Behavior: Yawning, Laughing, Hiccupping, and Beyond (Harvard University Press; 2012) 246 pages; examines the evolutionary context for humans
  • Shubin, Neil (February 2008). "Fish Out of Water". Natural History. 117 (1): 26–31. INIST:19986878. – hiccup related to reflex in fish and amphibians.
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