Can MS cause hiccups?
Have you ever had persistent hiccups? How long did the attack last and what treatments worked?
Case study
Dear Prof Giovannoni, I suddenly developed hiccups that lasted nearly three weeks. I hiccup 6-8 times per minute, affecting my eating and stopping me from falling asleep quickly. When I called my MS nurse, she said the hiccups were unlikely due to MS and suggested I see my GP to exclude gastrointestinal reflux. My GP seems at a loss and has given me a trial of lansoprazole in case I have reflux and a trial of prochlorperazine to try and suppress the hiccups. The only time I had acid reflux was during pregnancy. Could hiccups be due to MS?
Prof G’s opinion
Yes, hiccups or hiccoughs can rarely be the presenting symptom in MS or a symptom and sign of an MS relapse. Transient hiccups are an almost universal phenomenon at some point in a person’s life, i.e. they are normal. However, when they persist longer than a few hours, they are usually associated with several possible conditions (see below). Hiccups occur due to the involuntary contraction of the diaphragm and intercostal muscles (accessory muscles of respiration between the ribs). The closure of the glottis or larynx produces the characteristic “hic” sound. Persistent hiccups can affect eating, sleeping, speaking and social activities and impact quality of life.
Causes
Hiccups can be associated with gastroesophageal reflux, gastric distension from a large meal or drinking fizzy beverages, and irritation from eating spicy foods or drinking alcohol. Rarely oesophageal tumours can present with persistent hiccups. Anxiety, when accompanied by hyperventilation and aerophagia (air swallowing), can trigger attacks of hiccups. Some drugs are associated with hiccups, particularly alcohol, benzodiazepines, chemotherapeutic agents, steroids and anaesthetic agents.
Cardiovascular disorders, such as atrial pacing, aortic aneurysms, atrial fibrillation, myocardial infarction and pericarditis, can trigger hiccups, presumably by irritating the diaphragm. Similarly, ear, nose and throat disorders are also associated with hiccups due to stimulation of the phrenic nerve supplying the diaphragm. Several metabolic disorders are associated with hiccups; these include renal failure, diabetes and disturbances of blood electrolytes and calcium. Hiccups can be psychogenic in patients with extreme stress or as part of a somatisation disorder or malingering. Finally, almost all disorders of the central nervous system (CNS), including MS, can trigger hiccups. Common to these disorders is the involvement of the brainstem and the neurones that control the diaphragm and breathing mechanisms.
Before simply saying your hiccups are due to MS, I would need to take a detailed history, examine you, and maybe do some investigations. If MS is the cause of your hiccups, it could indicate that you are having an MS relapse, typically with a new lesion in the brain stem. I would be very interested to see if you had any other brainstem signs to suggest an MS relapse. I have written about this in the past. Please see MS-Selfie Newsletter ‘Has MS affected your brainstem and cerebellum?’ (01-Oct-2021) to get a clue about other brainstem symptoms and signs.
Please be aware that hiccups typically repeat in cycles with a frequency of between 4 and 60 per minute. The diaphragmatic spasm can be unilateral or bilateral, with the left hemidiaphragm being more commonly involved than the right. For those interested in anatomy, this may be due to the longer course of the recurrent laryngeal nerve on the left. Rarely, hiccups may persist as a form of myoclonus due to the excess activity of a group of neurones in the brain stem.
Treatment
Hiccups can be inhibited by raising carbon dioxide levels in the blood, i.e., by breath-holding or rebreathing air using a bag. Valsalva or vagal manoeuvres, such as trying to breathe out hard against a closed glottis, may break the spell. Drugs that work via GABA receptors, such as baclofen, may help. Dopamine blockers, e.g. prochlorperazine, chlorpromazine, haloperidol, and metoclopramide, are the most commonly prescribed medications for hiccups. This is why your GP prescribed prochlorperazine. Please let us know if your hiccups settle on this medication. Amantadine and the gabapentinoids (gabapentin and pregabalin) may also work. Clearly, if you are having a relapse, a course of steroids may also help. I would like to know if you develop other brainstem symptoms over the next few days or weeks.
Prognosis
I must have seen about 20 patients over 30 years of MS practice with MS-related hiccups due to a brainstem relapse. The hiccups eventually settled in all of these patients over days to weeks. The longest time I have seen persistent hiccups has been about 12 weeks. So my prognosis is favourable; I expect your hiccups to settle soon.
How many of you have had hiccups as part of a relapse? Did any of you have persistent hiccups as part of your initial presentation? And what treatments helped?
I suspect the odds of this person’s hiccups being MS-related are high. But as always, we must not assume every symptom you develop is due to MS. This patient deserves a full assessment and workup to ensure he/she does not have another cause to explain their hiccups. An alternative diagnosis may require a different treatment.
Paper
Hiccups is a rare and unfamiliar presenting symptom of multiple sclerosis. Patients admitted to Ramathibodi Hospital from 1969 to 1992 who had a clinical diagnosis of multiple sclerosis were reviewed The presenting symptoms and neurological signs were analysed. The clinical features and course of the disease of cases who initially presented with intractable hiccups were studied in detail. There were 4 cases out of a total of 47 cases (8.5%) who presented with hiccups. These patients all had relapse and remission and two of them had a rather fulminant course of illness. Therefore, multiple sclerosis should be seriously considered as a possible cause of intractable hiccups. It may be of benign or malignant form. In the latter, the patients may develop quadriparesis within hours or days and respiratory failure may ensue. They usually respond well to high dose intravenous corticosteroids especially pulse methylprednisolone.
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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust. The advice is intended as general and should not be interpreted as personal clinical advice. If you have problems, please tell your healthcare professional, who will be able to help you.
I only occasionally get hiccups. I can usually control them reasonably well. I had not connected this with MS. I am aware of swallowing issues and I am more mindful to eat at a a slower pace. So far so good.
I always associated the hiccups with swallowing issues. It requires more muscular effort to swallow, which I assumed meant I was taking in more air in the process, increasing the risk of hiccups. They almost always come when I eat. Alcohol and rich food are particular triggers. I have become quite good at controlling them though, through deep breaths, holding my breath, a glass of water, etc.