DEAR DR. ROACH: My friend has been struggling with almost never-ending hiccups since she was young. There seems to be no apparent trigger for them. They happen all hours of the day and even wake her up in the middle of the night. She will hiccup until it starts to become very painful for her, and she cannot make them stop. She’s tried every remedy she can find — drinking water, holding her breath and slowly letting out, even doing handstands, just to name a few.

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? What kind of specialist treats this problem? — N.E.

ANSWER: Persistent hiccups can be a severe problem. The hiccup (“singultus,” in Latin) 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, despite exhaustive searches for cures. 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 — Aldomet, an old blood pressure medicine; diazepam (Valium); and dexamethasone, a steroid similar to prednisone — are known causes.

Enlarged thyroid (goiter) and enlarged lymph nodes are causes of irritation to the phrenic nerve, which controls the diaphragm. Oddly, irritation in the external ear (such as by a hair) can stimulate the vagus nerve, which can affect the phrenic nerve via a neurological reflex, 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, like heartburn or cough. A stroke is a known cause, but that does not seem likely for your friend.

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. Because undiagnosed GERD can be a cause, it may be worth trying a proton pump inhibitor, such as omeprazole.

I read quite a few articles about hiccups to research this answer, and found that neurologists, ENT doctors, pulmonologists and gastroenterologists all have identified themselves as hiccup experts, which shows that it requires broad expertise to understand and treat this condition.

DEAR DR. ROACH: I’m 61 years old and came down with facial shingles 11 months ago on my right side. The pain started in my ear, moved to my eye and then the entire side of my face and scalp. It was a severe case. I still suffer with post-herpetic neuralgia pain and itching. Just last month, I had a mild case (forehead and bridge of nose) on my left side, which I guess is rare but happens. Should I get the shingles vaccine to prevent more incidents in the future? My doctor and neurologist say it won’t help, and two other doctors say it will but that I should let my immune system get stronger before getting it. — S.R.

ANSWER: Another case of shingles is very unlikely; however, the downside of the vaccine, beyond a sore arm, is small. Vaccination will not help with the post-herpetic neuralgia, which is persistent nerve pain after shingles. Hopefully that will go away; it usually does.

You can get the shingles vaccine as long as the rash is gone.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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