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Hangovers are a frequent, though unpleasant, experience among people who drink to
intoxication. Despite the prevalence of hangovers, however, this condition is not well
understood scientifically. Multiple possible contributors to the hangover state have been
investigated, and researchers have produced evidence that alcohol can directly promote
hangover symptoms through its effects on urine production, the gastrointestinal tract, blood
sugar concentrations, sleep patterns, and biological rhythms. In addition, researchers
postulate that effects related to alcohol’s absence after a drinking bout (i.e., withdrawal),
alcohol metabolism, and other factors (e.g., biologically active, nonalcohol compounds in
beverages; the use of other drugs; certain personality traits; and a family history of
alcoholism) also may contribute to the hangover condition. Few of the treatments commonly
described for hangover have undergone scientific evaluation. K EY WORDS : post AOD
intoxication state; symptom; urinalysis; gastrointestinal disorder; hypoglycemia; sleep
disorder; circadian rhythm; ethanol metabolite; disorder of fluid or electrolyte or acid-base
balance; nutrient intake; headache; vomiting; neurotransmitter receptors; congenors;
multiple drug use; personality trait; family AODU (alcohol and other drug use) history;
drug therapy; literature review
such as job performance and driving. toms include dizziness; a sense of the zero were tested following alcohol
In addition, researchers know little room spinning (i.e., vertigo); and intoxication with peak BAC’s in the
about hangover prevention and treat- possible cognitive and mood distur- range of 50 to 100 milligrams per
ment. Although folk remedies for bances, especially depression, anxiety, deciliter (mg/dL), most of them did
hangovers abound, their efficacy in and irritability. The particular set of not show significant impairments in
reducing the intensity and duration symptoms experienced and their inten- the performance of simple mental
of a hangover has not received system- sity may vary from person to person tasks, such as reaction time (Lemon et
atic study. In fact, some researchers and from occasion to occasion. In al. 1993). Similarly, several studies
and clinicians question whether finding addition, hangover characteristics may that investigated the hangover effects
an effective treatment for hangovers depend on the type of alcoholic beverage on a more complex mental task (i.e.,
is desirable, given that the hangover consumed and the amount a person simulated automobile driving) did not
experience may deter some people drinks. Typically, a hangover begins report impaired performance (Streufert
from engaging in subsequent episodes within several hours after the cessation et al. 1995; Tornros and Laurell 1991).
of heavy drinking. of drinking, when a person’s blood In contrast, a study of military pilots
Although gaps clearly remain in alcohol concentration (BAC) is falling. completing a simulated flying task
scientific knowledge about hangovers, Symptoms usually peak about the revealed significant decrements in
research has elucidated several aspects. time BAC is zero and may continue some performance measures (particu-
This article describes what is known for up to 24 hours thereafter. larly among older pilots) 8 to 14 hours
about the hangover condition, the Overlap exists between hangover and after they had consumed enough alco-
possible physiological factors contribut- the symptoms of mild alcohol with- hol to be considered legally drunk
ing to it, and treatment options. drawal (AW), leading to the assertion (Yesavage and Leirer 1986).
that hangover is a manifestation of
mild withdrawal. Hangovers, how-
What Is a Hangover? ever, may occur after a single bout of Prevalence of Hangover
drinking, whereas withdrawal occurs
A hangover is characterized by the usually after multiple, repeated bouts. Generally, the greater the amount
constellation of unpleasant physical Other differences between hangover and duration of alcohol consumption,
and mental symptoms that occur after and AW include a shorter period of the more prevalent is the hangover,
a bout of heavy alcohol drinking (see impairment (i.e., hours for hangover although some people report experi-
table 1). Physical symptoms of a versus several days for withdrawal) encing a hangover after drinking low
hangover include fatigue, headache, and a lack of hallucinations and seizures levels of alcohol (i.e., one to three
increased sensitivity to light and in hangover. alcoholic drinks), and some heavy
sound, redness of the eyes, muscle People experiencing a hangover feel drinkers do not report experiencing
aches, and thirst. Signs of increased ill and impaired. Although a hangover hangovers at all. A survey by Harburg
sympathetic nervous system activity may impair task performance and and colleagues (1993) on the preva-
can accompany a hangover, including thereby increase the risk of injury, lence of hangovers found that approx-
increased systolic blood pressure, equivocal data exist on whether hang- imately 75 percent of the subjects
rapid heartbeat (i.e., tachycardia), over actually impairs complex mental who drank to intoxication reported
tremor, and sweating. Mental symp- tasks. When subjects with a BAC of experiencing a hangover at least some
of the time. In a study of 2,160 Finnish
men, researchers found an association
Table 1 Symptoms of Hangover between increased weekly alcohol
consumption and the frequency of
Class of Symptoms Type hangover: 43.8 percent of the group
of heaviest drinkers (i.e., study subjects
Constitutional Fatigue, weakness, and thirst who drank more than 106 grams [g]
Pain Headache and muscle aches of alcohol per week or approximately
Gastrointestinal Nausea, vomiting, and stomach pain 9 drinks) reported experiencing a hang-
Sleep and biological rhythms Decreased sleep, decreased REM,1 over monthly or more often, compared
and increased slow-wave sleep with 6.6 percent of the remaining
Sensory Vertigo and sensitivity to light and sound
study subjects (Kauhanen et al. 1997).
Cognitive Decreased attention and concentration
Mood Depression, anxiety, and irritability
Similarly, in a study of 1,041 drinkers
Sympathetic hyperactivity Tremor, sweating, and increased pulse in New York State, 50 percent of the
and systolic blood pressure subjects who drank two or more drinks
per day reported experiencing hang-
1
REM = rapid eye movements. overs in the previous year, whereas
subjects who consumed lower levels
Disruption of Sleep and Other the most common type of headache AW overlap considerably. The revised
Biological Rhythms. Although alcohol reported (Rasmussen and Olesen 1992). Clinical Institute Withdrawal Assess-
has sedative effects that can promote Alcohol intoxication results in vasodi- ment for Alcohol (CIWA-Ar) scale, an
sleep onset, the fatigue experienced latation, which may induce headaches. instrument widely used to assess the
during a hangover results from alcohol’s Alcohol has effects on several neuro- severity of a withdrawal episode in
disruptive effects on sleep. Alcohol- transmitters and hormones that are alcohol-dependent patients, measures
induced sleep may be of shorter duration implicated in the pathogenesis of head- 10 withdrawal-associated items: nausea
and poorer quality because of rebound aches, including histamine, serotonin, and vomiting; tremor; sweating; anxi-
excitation (see the section “Effects of and prostaglandins (Parantainen 1983). ety; agitation; headache; disturbances
Alcohol Withdrawal”) after BAC’s fall, However, the etiology of hangover in the sense of touch, hearing, and
leading to insomnia (Walsh et al. 1991). headache remains unknown. vision (e.g., hallucinations); and orien-
Furthermore, when drinking behavior tation (e.g., awareness of the date and
takes place in the evening or at night location) (Sullivan et al. 1989, see also
(as it often does), it can compete with
Effects of Alcohol Withdrawal p. 8 of the article by Saitz for a sample
sleep time, thereby reducing the length The AW syndrome following the of the assessment form). Several of
of time a person sleeps. Alcohol also cessation of excessive drinking results these items also are usually present
disrupts the normal sleep pattern, from compensatory changes in the during a hangover, including nausea
decreasing the time spent in the dream- central nervous system that take place and vomiting, tremor, sweating, anxiety,
ing state (i.e., rapid eye movement [REM] in response to chronically administered headache, and sensory disturbances.
sleep) and increasing the time spent depressant substances (in this case, Second, Begleiter and colleagues
in deep (i.e., slow-wave) sleep. In alcohol, or more specifically, ethanol). (1974) present evidence that the
addition, alcohol relaxes the throat These changes include alterations in hangover condition is actually a state
muscles, resulting in increased snoring two types of receptors embedded in of central nervous system excitation,
and, possibly, periodic cessation of nerve cell membranes. One receptor despite the perceived sedation and
breathing (i.e., sleep apnea). type binds with an important chemi- malaise. Support for this view comes
Alcohol interferes with other biolog- cal messenger (i.e., neurotransmitter) from the research of Pinel and Mucha
ical rhythms as well, and these effects called gamma-aminobutyric acid (1980), which shows that single doses
persist into the hangover period. For (GABA), and the other type binds of alcohol decrease seizure thresholds
example, alcohol disrupts the normal with another neurotransmitter, gluta- in animals several hours later. Their
24-hour (i.e., circadian) rhythm in body mate. Both GABA and glutamate are finding indicates rebound excitation,
temperature, inducing a body temper- critical in regulating nerve cell activity: a phenomenon noted to occur after
ature that is abnormally low during GABA is the body’s primary means short-term administration of some
intoxication and abnormally high during of inhibiting nerve cell activity, and sedatives that can quickly clear the
a hangover. Alcohol intoxication also glutamate is the primary means of body, including alcohol and certain
interferes with the circadian nighttime exciting it. benzodiazepine drugs.
secretion of growth hormone, which Following chronic alcohol exposure, Third, the observation that alcohol
is important in bone growth and the body decreases (i.e., downregulates) readministration alleviates the unpleas-
protein synthesis. In contrast, alcohol the number or sensitivity of GABA antness of both AW syndrome and
induces the release of adrenocortico- receptors and increases (i.e., upregulates) hangovers suggests that the two expe-
tropic hormone from the pituitary the number or sensitivity of glutamate riences share a common process.
gland, which in turn stimulates the receptors in an effort to counterbalance
release of cortisol, a hormone that plays alcohol’s sedative effects. When alcohol
a role in carbohydrate metabolism and is removed from the body, however, the
Effects of Alcohol Metabolites
stress response; alcohol thereby disrupts central nervous system and the portion Alcohol undergoes a two-step process
the normal circadian rise and fall of of the nervous system that coordinates in its metabolism (see figure). First, an
cortisol levels. Overall, alcohol’s disrup- response to stress (i.e., the sympathetic enzyme (i.e., alcohol dehydrogenase)
tion of circadian rhythms induces a nervous system) remain in an unbal- metabolizes alcohol to an intermediate
“jet lag” that is hypothesized to account anced “overdrive” state (Tsai et al. 1995). product, acetaldehyde; then a second
for some of the deleterious effects of a Sympathetic nervous system hyperac- enzyme (aldehyde dehydrogenase
hangover (Gauvin et al. 1997). tivity accounts for the tremors, sweating, [ALDH]) metabolizes acetaldehyde to
and tachycardia observed in both hang- acetate. Acetaldehyde is a chemically
over and AW syndrome. reactive substance that binds to pro-
Alcohol and Headache Several lines of evidence suggest that teins and other biologically important
In a large epidemiological survey of a hangover is a mild manifestation of compounds. At higher concentrations,
headache in Danish 25- to 64-year-olds, the AW syndrome in non-alcohol- it causes toxic effects, such as a rapid
the lifetime prevalence of hangover dependent drinkers. First, the signs pulse, sweating, skin flushing, nausea,
headache was 72 percent, making it and symptoms of hangover and mild and vomiting. In most people, ALDH
Andrew Scale [MacAndrew 1965]). Attentiveness to the quantity and enhances acetaminophen’s toxicity to
Those studies suggest that people who quality of alcohol consumed can have the liver (Girre et al. 1993).
have an elevated personality risk for a significant effect on preventing hang- Propranolol, a beta-adrenergic
alcoholism experience more acute over. Hangover symptoms are less antagonist1 used to treat high blood
withdrawal and hangover symptoms likely to occur if a person drinks only pressure and migraine headaches, re-
and may initiate further drinking in an small, nonintoxicating amounts. Even duces the sympathetic hyperactivity
effort to find relief. among people who drink to intoxication, of AW; however, a small, double-blind,
Research has shown that a history those who consume lower amounts of placebo-controlled study did not find
of alcoholism in a person’s family (i.e., alcohol appear less likely to develop a propranolol to be effective in reducing
a positive family history) is associated hangover than those who drink higher hangover symptoms, including headache
with a decreased sensitivity to the intox- amounts. Hangovers have not been (Bogin et al. 1987). Antagonists at the
icating effects of alcohol and a greater associated with drinking beverages with serotonin-3 receptor,2 such as ondan-
risk for developing alcoholism (Schuckit a low alcohol content or with drinking setron and tropisetron, are antiemetics
and Smith 1996). Newlin and Pretorius nonalcoholic beverages. (i.e., they control nausea and vomiting)
(1990) suggested that a positive family The type of alcohol consumed also and block certain alcohol effects; how-
history for alcoholism may be associated may have a significant effect on reduc- ever, a small clinical trial did not show
with a tendency for increased hangover ing hangover (Chapman 1970; Pawan efficacy in alleviating hangover (Muh-
symptoms as well. Their research 1973). Alcoholic beverages that contain onen et al. 1997). Caffeine (often taken
compared the self-reported hangover few congeners (e.g., pure ethanol, vodka, as coffee) is commonly used to counter-
symptoms in college-age sons of alco- and gin) are associated with a lower act the fatigue and malaise associated
holic fathers with symptoms in sons incidence of hangover than are beverages with the hangover condition. Although
of nonalcoholic fathers and found that contain a number of congeners this traditional practice lacks scientific
that the subjects with a positive fam- (e.g., brandy, whiskey, and red wine). support, William Hickey, quoted at the
ily history for alcoholism had had Other interventions may reduce the beginning of this article, wrote that
greater hangover symptoms during the intensity of a hangover but have not “very strong coffee proved of infinite
previous year. The amount of drink- been systematically studied. Consump- benefit” (Spenser 1913).
ing was comparable between the two tion of fruits, fruit juices, or other Readministration of alcohol—the
groups, although the subjects with a fructose-containing foods is reported “hair of the dog that bit you” remedy—
positive family history reported con- to decrease hangover intensity, for reportedly cures a hangover, but people
suming significantly more mixed example (Seppala et al. 1976). Also, experiencing a hangover should avoid
drinks than the group with a negative bland foods containing complex car- further alcohol use. Additional drink-
family history. bohydrates, such as toast or crackers, ing will only enhance the existing
can counter low blood sugar levels in toxicity of the alcohol consumed during
people subject to hypoglycemia and the previous bout and may increase the
Treatments for Hangover can possibly relieve nausea. In addition, likelihood of even further drinking.
adequate sleep may ease the fatigue
Many treatments are described to pre- associated with sleep deprivation, and
vent hangover, shorten its duration, drinking nonalcoholic beverages during Areas for Future Study
and reduce the severity of its symptoms, and after alcohol consumption may
including innumerable folk remedies reduce alcohol-induced dehydration. Several topics related to hangovers
and recommendations. Few treatments Certain medications may provide warrant research attention. The effect
have undergone rigorous investigation, symptomatic relief for hangover symp- of congeners, especially methanol, on
however. Conservative management toms. For example, antacids may alleviate the occurrence of hangover needs closer
offers the best course of treatment. nausea and gastritis. Aspirin and other examination, for example. Such research
Time is the most important compo- nonsteroidal anti-inflammatory medi- could help determine whether it is
nent, because hangover symptoms cations (e.g., ibuprofen or naproxen) ethanol or congeners that produce the
will usually abate over 8 to 24 hours. may reduce the headache and muscle major signs and symptoms of hangover,
aches associated with a hangover but and an answer to this key question
1
An antagonist is an agent that interferes with or should be used cautiously, particularly would advance our understanding of
blocks the action of another agent, disease, or if upper abdominal pain or nausea is hangover pathophysiology.
structure. A beta-adrenergic antagonist blocks the present. Anti-inflammatory medications A particularly intriguing observation
action of certain neurotransmitters governing the
sympathetic nervous system.
are themselves gastric irritants and is that people with traits associated with
will compound alcohol-induced gas- an increased risk for alcoholism (e.g.,
2
Serotonin antagonists block the actions of tritis. Although acetaminophen is a certain personality factors or a positive
serotonin, a neurotransmitter that can affect
mood as well as inhibit gastric secretion and
common alternative to aspirin, its use family history for alcoholism) experience
stimulate smooth muscle, such as that governing should be avoided during the hangover more severe hangovers. Although logic
the contractions of the digestive system. period, because alcohol metabolism dictates that enduring more severe or