A Therapeutic Paradox: Intractable Hiccups in Acute Stroke and Vascular Parkinsonism Following Initiation of Carbidopa/Levodopa

Intractable hiccups are an uncommon but clinically significant condition that can lead to sleep disturbance, fatigue, impaired oral intake, and reduced quality of life. The hiccup reflex arc involves complex peripheral and central pathways, with dopaminergic signaling believed to play a modulatory role. In neurologically complex patients, distinguishing medication-related hiccups from structural central nervous system etiologies remains challenging. We present a 94-year-old male with a history of vascular Parkinsonism and multiple comorbidities who was admitted for acute ischemic stroke involving the right frontal, parietal, and temporal lobes and insula. During his subsequent acute inpatient rehabilitation course, he developed new-onset intractable hiccups occurring approximately every 5 seconds and persisting during sleep, resulting in significant functional impairment. Initial management with metoclopramide and proton pump inhibitor therapy was ineffective, and no pulmonary or gastrointestinal etiology was identified. Given concern for a potential medication contribution in the setting of dopaminergic therapy initiated during hospitalization, carbidopa/levodopa was discontinued. Treatment with chlorpromazine led to progressive resolution of symptoms. This case highlights a complex therapeutic and diagnostic dilemma in which acute cerebrovascular injury and dopaminergic therapy may have jointly contributed to the disruption of the hiccup reflex arc. It underscores the importance of considering both central neurologic and pharmacologic etiologies in intractable hiccups and illustrates the potential role of dopamine antagonism in symptom control within a medically and neurologically vulnerable population.