Table 1 enlists the various causes of a hiccup. In cases of known underlying pathology treatment of the causative factor may help relieve the symptoms. As such most initial remedies seem to centre on over stimulating the Vagus nerve. The “wanderer” has such immense distribution throughout the body that the reflex can be triggered by any number of odd reasons such as irritation of the ear drum, rapid change in body temperature, over distension of stomach, irritation of the respiratory tractor stroking of hair. Of these the Vagus is particularly important. There is no conclusive knowledge on how this reflex is triggered but a safe idea would be that any mechanism which irritates or damages the components of the reflex arc, the central nuclei, the Vagus, phrenic or other nerves of the autonomic system can trigger a hiccup. This is followed, in 35 milliseconds, by an abrupt glottal closure producing the typical “hicc”. When the hiccup reflex is triggered there is synchronous contraction of the inspiratory thoracic muscles and the diaphragm. It is speculated that the hiccup centre and the respiratory centre although separate may interact with one another through the various neuronal connections. Gama-aminobutyric acid (GABA) and dopamine act as neurotransmitters for this reflex. The hiccup central connection is believed to be spinal cord segments rostral to medulla oblongata (C3-5) in the reticular formation in the middle and dorsolateral segment, connecting to the hiccup rhythm centre in the Pre-Botzinger complex, nucleus ambiguous, lateral reticular nucleus, hypothalamus and mesial temporal lobes, ,, ]. The efferent pathway is constituted by the phrenic nerve (C3-5) innervating the diaphragm, plexal branches to the scalene muscles (C5-7), recurrent laryngeal nerve to the glottis and the intercostal nerves (T1-11) innervating the intercostal muscles. The afferent limb is composed of the Vagus and phrenic nerves, and the lower sympathetic (T6-12) segments. The hiccup reflex arc can be categorised as having afferent and efferent limbs and a central connection. Even the word “hiccup” is an onomatopoeic for the sound the reflex arc produces. Although much is known about the afferent and efferent limbs of the hiccup reflex pathway, no definitive consensus exists on the hiccup centre generating this reflex.

Hiccup is a widely experienced and less understood phenomenon. Here the authors report a case of VNS placement for intractable hiccups with partial success, in accordance with SCARE-2018 guidelines. A novel surgical strategy is emerging in the form of Vagus nerve stimulator (VNS) placement with three cases cited in literature to date with varying degrees of success. Surgical intervention, although undertaken very rarely, predominantly revolves around phrenic nerve crushing, blockade or pacing.

Medical refractory cases even indulge in unconventional therapies such as hypnosis, massages and acupuncture. Pharmacotherapy with baclofen, gabapentin and other centrally and peripherally acting agents such as chlorpromazine and metoclopramide are reserved as second line treatment. Initial remedies such as drinking cold water, induction of emesis, carotid sinus massage or Valsalva manoeuvre all seem to work by over stimulating the Vagus nerve. Intractable hiccups frequently result from an underlying pathology and can cause considerable illness in the patients.

Persistent hiccups postview became