Reasoning GP · Algorithm · 1-page summary
Hiccups — acute, persistent and intractable
For: people with hiccups in primary care. Not for: chest pain or dysphagia as the main problem (chest pain, dysphagia algorithms). Known malignancy: manage with the palliative-care team per the local palliative protocol.
Core rule: acute hiccups (<48 hours) with a clear trigger in a well patient are benign. Beyond 48 hours hiccups are a symptom, not a diagnosis — look for reflux, a metabolic disturbance, a drug cause or central pathology before drug treatment.
0Stop — call 999 now — brainstem, cardiac, raised pressure
- Sudden-onset neurological symptoms or signs with hiccups (diplopia, ataxia, facial weakness, dysarthria) — possible brainstem stroke → 999
- Suspected ACS (chest pain now, or in the last 12 hours with an abnormal or unavailable ECG), suspected PE with instability, aortic dissection or haemodynamic compromise → 999. Do not delay for a primary-care troponin.
- Rapidly deteriorating consciousness in known malignancy (raised intracranial pressure from cerebral metastases) → 999
1Triage by duration
| Duration | Action |
|---|---|
| Acute <48 hours | Clear benign trigger, well → reassure, simple measures, no tests |
| Persistent 48 h – 1 month | Focused history, examination, medication review, targeted tests |
| Intractable >1 month | Specialist assessment and fuller investigation — also if sleep loss, dehydration, weight loss or unable to eat |
2Screen — serious causes
- Headache, vomiting, ataxia or other brainstem signs (not sudden) → Same-day neurology / A&E
- Other chest pain or breathlessness → Same-day assessment
- Uraemic symptoms with eGFR acutely deteriorating or rapidly rising creatinine → Same-day hospital (possible AKI)
- Dysphagia at any age (with or without hiccups), or ≥55 with weight loss + upper abdominal pain, reflux or dyspepsia → Upper-GI suspected cancer pathway. Hiccups alone do not meet NG12.
- New on dexamethasone, opioids, chemotherapy or benzodiazepines → medication review first.
3Assess — persistent or intractable
☐ Triggers, dysphagia, heartburn, weight loss, neurological symptoms ☐ Drugs, alcohol, malignancy, CKD ☐ Pharynx, neck, ear canal, heart, chest, abdomen; neurology if any neurological feature
Consider, guided by the picture: U&E + eGFR, calcium (± magnesium), glucose, FBC, LFTs; ECG if chest symptoms, cardiac disease or QT-prolonging drugs; CXR by indication. No routine MRI brain if examination is normal.
4Classify — only if the screen is negative
- GORD / gastric distension (commonest) → PPI trial.
- Drug-induced (dexamethasone commonest) → review with the prescribing team.
- Metabolic — uraemia, hyponatraemia, hypocalcaemia, hypokalaemia → correct per local protocols.
- Alcohol or post-operative — alcohol history in all.
- Structural (CNS, thoracic, abdominal) → imaging by indication, specialty referral.
- Uncertain / functional — only after organic causes are excluded; some remain idiopathic.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Simple measures: brief breath-hold, cold water, swallow sugar, Valsalva only if safe — no paper bag. Small slow meals, no fizzy drinks.
- Reflux suspected: PPI (e.g. omeprazole 20 mg OD) for 4 weeks, then reassess. Metoclopramide only if stasis or reflux and obstruction excluded, ≤5 days; no routine domperidone.
- Baclofen may be considered off-label after assessing the cause, usually with specialist advice: check renal function, start cautiously, taper — never stop abruptly.
- Chlorpromazine, haloperidol, gabapentin, midazolam → specialist or palliative protocol only.
6Refer routinely
- Gastroenterology: GORD features not responding to PPI at 4 weeks; suspected gastroparesis.
- Neurology: intractable with neurological features or unexplained after assessment; known MS with new persistent hiccups.
- Palliative care: intractable with malignancy, or impaired sleep or nutrition in serious illness.
- Functional, confirmed after organic exclusion → CBT / NHS Talking Therapies.
7Never reassure by
- Assuming hiccups are psychogenic before organic causes are considered.
- Calling it reflux when there is dysphagia or weight loss.
- A single primary-care troponin in someone with chest pain.
- Starting drug treatment before checking U&E, calcium, glucose and the drug list.
- Stopping dexamethasone or baclofen yourself — agree changes with the team.
- Treating functional hiccups with benzodiazepines (they cause hiccups).
8Safety-net — say it, then document it
999 “Call 999 for chest pain, or new double vision, unsteadiness, facial weakness or slurred speech.” Same day “Contact us the same day for new difficulty swallowing or weight loss, or if hiccups last beyond 48 hours despite simple measures.”
Routine “On baclofen, do not stop it suddenly — follow the taper agreed with your specialist.” Results reviewed promptly and the plan shared with the patient.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Duration classified; examination done if >48 hours
Drugs, alcohol, U&E, calcium, glucose reviewed
Cause treated; PPI review at 4 weeks booked
48-hour return rule and 999 words given
Summary of the full Reasoning GP hiccups algorithm, which holds the history, examination, causes, treatment ladder and evidence. Sources: NICE NG12 (updated April 2026), CG184, CG95, CG113; Scottish Palliative Care Guidelines (hiccups); MHRA SPCs; local palliative-care hiccups protocol. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.