Can Anesthesia Cause Hiccups? Causes and Treatments

Anesthesia can cause hiccups, and it does so through several different mechanisms depending on the drugs used and the procedures performed. Multiple anesthetic agents, including propofol, midazolam, opioids, and inhaled anesthetics like isoflurane, have been linked to hiccups during or after surgery. While most cases are brief and resolve on their own, perioperative hiccups occasionally persist for days and create real problems for both the surgical team and the recovering patient.

How Common Are Hiccups During and After Surgery

Among general hospital inpatients, hiccups occur in roughly 1 in 2,000 admissions. That sounds rare until you consider how many surgeries happen each day in a busy hospital. Certain patient populations face higher odds: people with gastroesophageal reflux disease (GERD) or hiatal hernias experience hiccups at a rate closer to 10%, and patients with esophageal tumors see rates as high as 27% for episodes lasting more than 48 hours.¹ What makes the surgical setting special is that multiple triggers converge at once: anesthetic drugs acting on the brain, tubes and devices touching sensitive airway tissue, and abdominal manipulation all happening within a short window.

The Reflex That Gets Hijacked

A hiccup is not just a random spasm. It follows a specific reflex loop with three parts: incoming nerve signals (carried by the phrenic nerve, vagus nerve, and sympathetic fibers), a processing center in the brainstem, and outgoing signals that trigger a sharp contraction of the diaphragm and the muscles between the ribs.² The glottis snaps shut almost immediately after the diaphragm contracts, producing the characteristic “hic” sound. Anything that irritates or stimulates any part of this loop can set off the reflex, and anesthesia offers plenty of opportunities to do exactly that.

The vagus nerve is a particularly common culprit. It runs from the brainstem all the way down through the neck, chest, and abdomen, passing near the esophagus, the heart, and the stomach along the way. Surgical instruments, airway devices, and even the movement of a breathing tube can brush against branches of this nerve. The phrenic nerve, which controls the diaphragm directly, is another vulnerable target. Sympathetic nerve fibers in the lower chest round out the incoming side of the arc.³ Between these three nerve pathways, almost every structure encountered during surgery has a direct line to the hiccup reflex.

Which Anesthetic Drugs Trigger Hiccups

Not all anesthetic agents carry the same risk. The drugs most commonly linked to perioperative hiccups fall into a few categories, each with its own suspected mechanism.

Propofol

Propofol is one of the most widely used intravenous anesthetics, favored for its rapid onset and quick recovery. Hiccups during propofol induction are recognized as an uncommon but real side effect. The exact reason is still debated: researchers suspect it involves a brief period of subcortical disinhibition as the drug takes effect, along with possible direct stimulation of the vagus nerve.⁴ In most cases, propofol-induced hiccups stop within minutes. But when they persist during a procedure requiring the patient to hold still, such as an MRI scan, even a few minutes of rhythmic diaphragm jerks can force the team to pause and intervene.

Midazolam

Midazolam, a benzodiazepine commonly given before surgery for sedation and anxiety, is another frequent offender. In adults undergoing endoscopy, patients who received a higher dose of midazolam developed hiccups significantly more often than those given a lower dose.⁵ Children are not spared either: in a study of children given rectal midazolam as pre-medication before anesthesia, hiccups appeared in roughly one in four, regardless of whether the dose was standard or double.⁶

One telling case involved a patient who developed hiccups lasting nine days after orthopedic surgery. When he returned for a subsequent procedure and received midazolam alone, the hiccups returned. Administering flumazenil, a drug that reverses benzodiazepine effects, stopped the hiccups immediately.⁷ That kind of challenge-rechallenge evidence is about as close to proving a direct drug-hiccup link as you can get in clinical medicine.

Opioids

Opioid painkillers used during and after surgery, including morphine and fentanyl, can also trigger hiccups. In one reported case, a patient who received morphine during surgery and then a fentanyl infusion afterward developed frequent hiccup episodes starting on the first postoperative day.⁸ Opioids act on receptors throughout the brainstem and spinal cord, including areas that overlap with the hiccup reflex center. The association is well recognized, though it tends to get less attention than opioids’ better-known side effects like nausea and sedation.

Inhaled Anesthetics

Isoflurane, a commonly used inhaled anesthetic gas, has a complicated relationship with hiccups. Animal research shows that it simultaneously activates one type of receptor (GABA-A) that facilitates the hiccup reflex while also activating another type (GABA-B) that suppresses it. The net result at typical anesthetic concentrations is suppression, meaning the hiccup reflex is actually dampened in proportion to the gas concentration.⁹ But this dual mechanism helps explain why hiccups sometimes emerge at lighter planes of anesthesia, when the suppressive effect has not fully kicked in, or during transitions between different anesthetic depths.

In at least one clinical case, a dog developed persistent hiccup-like movements shortly after being induced with isoflurane. The movements did not respond to deepening the anesthesia or switching to a propofol infusion, and ultimately required a neuromuscular blocking agent to stop.¹⁰ While that is a veterinary case, it underscores that the reflex can sometimes resist the usual strategies for suppression.

Airway Devices and Surgical Manipulation

Drugs are only part of the story. The physical interventions involved in anesthesia and surgery can independently provoke hiccups. Laryngeal mask airways, which sit at the back of the throat rather than passing through the vocal cords like an endotracheal tube, have been specifically associated with intraoperative hiccups. These devices rest near vagus nerve branches in the pharynx, and their presence can be enough to trigger the reflex.¹¹

Surgeries involving the abdomen, chest, or esophagus carry additional risk because the operative field directly contacts structures along the vagus and phrenic nerve pathways. Even procedures that seem distant from the diaphragm can cause trouble. One case report describes persistent hiccups that began immediately after a lumbar epidural steroid injection and continued for three days before responding to treatment with chlorpromazine.¹² The mechanism in such cases likely involves drug spread to nerve roots or brainstem areas involved in the hiccup reflex rather than direct mechanical irritation.

Why Perioperative Hiccups Actually Matter

A brief bout of hiccups in the recovery room might seem like nothing more than an annoyance, but in the surgical setting, hiccups can create genuine clinical problems. Each hiccup involves a sudden, forceful contraction of the diaphragm that the patient cannot control. During surgery, these jolts can interfere with the surgical process, disrupt monitoring, and even delay the start of an operation. After surgery, persistent hiccups can compromise wound healing and affect blood pressure and heart rate stability.¹¹

Perhaps the most worrisome risk is aspiration. The repeated abrupt changes in pressure inside the chest and abdomen can push stomach contents upward, and if the airway is not fully protected, that material can enter the lungs. In a patient under sedation whose protective reflexes are already blunted, this risk is more than theoretical.

When Postoperative Hiccups Signal Something Else

Most post-surgical hiccups fade within hours. But when they persist for more than 48 hours, they cross the clinical threshold from “acute” to “persistent,” and clinicians start looking for underlying causes beyond the anesthetic itself. In one well-documented case, a patient with GERD developed 11 days of recurrent hiccups following an orthopedic procedure.¹³ That case highlighted something worth knowing: persistent hiccups are sometimes a presenting symptom of pulmonary embolism or cardiac problems. In a post-surgical patient, where blood clot risk is already elevated, hiccups that will not quit deserve more than a shrug.

Pre-existing conditions like GERD, hiatal hernia, and a history of stroke all raise the baseline risk. Stroke patients experience hiccups at a rate of about 0.3%, because the vascular damage can directly disrupt the brainstem pathways that regulate the hiccup reflex.¹ For someone with any of these conditions going into surgery, the anesthesia team is aware that hiccups may be more likely and more stubborn.

Treating Hiccups During and After Anesthesia

Treatment strategies exist along a spectrum from simple physical maneuvers all the way up to nerve blocks, and the choice depends on severity, timing, and what else is happening with the patient.

Physical and Vagal Maneuvers

The first-line approaches are non-pharmacological. Many of the folk remedies people use for everyday hiccups, like breath-holding and the Valsalva maneuver (bearing down as if straining), work by increasing vagal nerve activity, which can interrupt the reflex arc. Other vagal maneuvers include applying pressure to the eyeballs (the oculocardiac reflex), massaging the carotid sinus in the neck, stimulating the ear canal, and swallowing ice. These methods are often effective for acute bouts but tend to fail when hiccups have been going on for an extended period.¹⁴

In the operating room, clinicians have additional options. Pharyngeal stimulation, intranasal application of ice-cold water, and adjustments to ventilation, such as applying continuous positive pressure, have all been reported as effective in case reports and small series.¹⁵ For the study of children with midazolam-induced hiccups mentioned earlier, intranasal ethyl chloride spray was investigated as a treatment approach.⁶

Drug Treatments

When physical techniques fail, pharmacological options come next. Chlorpromazine, an antipsychotic, is one of the few drugs formally approved for treating hiccups and has been used successfully in post-surgical cases, including the persistent hiccups that followed the lumbar epidural injection described earlier. Metoclopramide, a drug that speeds gastric emptying, is another option. But both carry notable side effects including dizziness and sedation, which are particularly unwelcome in a patient recovering from anesthesia.

Baclofen, a muscle relaxant that acts on GABA-B receptors, has shown promise as an alternative. It targets the same receptor type that research on isoflurane identified as involved in suppressing the hiccup reflex. A case series found baclofen effective for persistent hiccups regardless of the underlying cause, and researchers have suggested it could be a better-tolerated option than chlorpromazine or metoclopramide.¹⁶

For propofol-induced hiccups specifically, dexmedetomidine, a sedative that works through a different pathway, has been used successfully to stop the reflex when propofol itself was the trigger.⁴ And as noted in the midazolam case, flumazenil can rapidly reverse hiccups when a benzodiazepine is the cause, which doubles as a diagnostic confirmation.⁷

Nerve Blocks for Intractable Cases

When hiccups resist both physical maneuvers and medications, anesthesiologists can target the reflex arc directly with nerve blocks. Ultrasound-guided phrenic nerve block, which temporarily paralyzes the diaphragm on one side, has been used successfully during surgery when other treatments failed.¹⁷ In one case of intractable postoperative hiccups following biliary tube removal, combining a phrenic nerve block with a stellate ganglion block (targeting sympathetic nerve fibers in the neck) produced rapid and complete resolution with no complications.¹⁸ These blocks are reserved for truly stubborn cases, but they illustrate a key principle: the more components of the reflex arc you can interrupt simultaneously, the better your odds of stopping the cycle.

Who Is Most at Risk

If you are heading into surgery and wondering whether hiccups are likely, a few factors raise the probability. GERD and hiatal hernia are the most consistent risk factors, because they involve chronic irritation of the vagus nerve at the junction between the esophagus and stomach. A history of prior anesthesia-related hiccups is also a red flag; the midazolam case that recurred on a second surgery suggests some people have an inherently more excitable hiccup reflex. Procedures involving the abdomen, chest, or esophagus bring surgical instruments closer to the key nerves. And certain drug choices, especially higher doses of midazolam, tip the odds further.

That said, the evidence here is mostly drawn from case reports and case series rather than large randomized trials, which means we do not have precise risk calculators. The honest picture is that perioperative hiccups are uncommon enough that most patients will never experience them, but unpredictable enough that anesthesia teams keep a mental playbook ready for when they do appear. If you have had trouble with hiccups during a previous procedure, mentioning it during your pre-anesthetic consultation gives your team a chance to adjust their drug selection or have treatments on hand from the start.

Lidocaine as an Emerging Option

One development worth noting is the growing interest in lidocaine, a local anesthetic with systemic effects, as a treatment for perioperative hiccups. A recent narrative review of the field highlighted emerging evidence for lidocaine’s therapeutic efficacy in this setting.¹⁹ Lidocaine is already widely available in operating rooms, has a well-understood safety profile when administered intravenously at controlled doses, and acts on sodium channels that play a role in nerve signal transmission. Its dual identity as both a local anesthetic and a systemic nerve-calming agent makes it a natural candidate for disrupting the hiccup reflex arc. Whether it earns a standard place in the treatment ladder will depend on future trials, but its accessibility and familiarity give it a practical advantage over some of the more specialized interventions currently in use.

1
Taylor & Francis Online (Annals of Medicine). Pathogenesis and treatment of perioperative hiccups: a narrative review – Section: Introduction
2
PubMed Central. Neurotransmitters in hiccups
3
Neurological Disorders. Hiccup – Section: Publisher Summary
4
PubMed Central. Propofol-induced hiccups in MRI suite treated with dexmedetomidine
5
PubMed Central. Sedation-associated hiccups in adults undergoing gastrointestinal endoscopy and colonoscopy
6
PubMed. Incidence and therapy of midazolam induced hiccups in paediatric anaesthesia
7
PubMed. Midazolam-Induced Hiccups Reversed by Flumazenil: A Case Report
8
PubMed Central. Persistent Opioid-Induced Hiccups: A Case Report
9
PubMed. Isoflurane facilitates hiccup-like reflex through gamma aminobutyric acid (GABA)A- and suppresses through GABAB-receptors in pentobarbital-anesthetized cats
10
PubMed Central. Hiccup-Like Response in a Dog Anesthetized with Isoflurane
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PubMed Central. Intraoperative Laryngeal Mask Airway-Related Hiccup: An Overview
12
PubMed Central. Persistent hiccup after lumbar epidural steroid injection
13
PubMed Central. Persistent Postoperative Hiccups
14
PubMed. Treatment of hiccup by vagal maneuvers
15
PubMed. Treatment of hiccup during general anaesthesia or sedation: a qualitative systematic review – Section: RESULTS
16
PubMed Central. Baclofen in the treatment of persistent hiccup: a case series – Section: Discussion
17
PubMed Central. Ultrasound-guided phrenic nerve block for intraoperative persistent hiccups: a case report – Section: CONCLUSIONS
18
PubMed Central. Phrenic nerve block combined with stellate ganglion block for postoperative intractable hiccups: a case report
19
Taylor & Francis Online (Annals of Medicine). Pathogenesis and treatment of perioperative hiccups: a narrative review