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and relevant clinical information was extracted.
he alcohol hangover has been well-known since
Data Synthesis: The alcohol hangover is characterized at least Biblical times: Woe unto them that
by headache, tremulousness, nausea, diarrhea, and fa-
rise up early in the morning, that they may follow
tigue combined with decreased occupational, cognitive, or
strong drink (Isaiah 5:11) (2). Medical investiga-
visualspatial skill performance. In the United States, re-
lated absenteeism and poor job performance cost $148
tion, however, has focused on the acute effects of
billion annually (average annual cost per working adult, alcohol ingestion. More than 4700 articles have
$2000). Although hangover is associated with alcoholism, been written about alcohol intoxication since 1965,
most of its cost is incurred by the light-to-moderate but only 108 have addressed alcohol hangover (35).
drinker. Patients with hangover may pose substantial risk Recent studies suggest that the alcohol hangover
to themselves and others despite having a normal blood induces cardiovascular and psychomotor morbidity
alcohol level. Hangover may also be an independent risk independent of the quantity of alcohol consumed or
factor for cardiac death. the frequency of ingestion (6 8).
Symptoms of hangover seem to be caused by dehydra-
tion, hormonal alterations, dysregulated cytokine path-
ways, and toxic effects of alcohol. Physiologic characteris-
tics include increased cardiac work with normal peripheral Methods
resistance, diffuse slowing on electroencephalography,
and increased levels of antidiuretic hormone. We searched the MEDLINE database (1965 to
Effective interventions include rehydration, prostaglan- 1999) for epidemiologic, physiologic, and economic
din inhibitors, and vitamin B6. Screening for hangover studies about alcohol hangover, using the terms
severity and frequency may help early detection of alcohol hangover, alcohol withdrawal, and alcohol intoxica-
dependency and substantially improve quality of life. Rec- tion. Bibliographies of selected articles and personal
ommended interventions include discussion of potential
communication with selected authors were used to
therapies and reminders of the possibility for cognitive
extend the search. Articles were screened for their
and visualspatial impairment. No evidence suggests that
alleviation of hangover symptoms leads to further alcohol relevance to the specific topic of alcohol hangover
consumption, and the discomfort caused by such symp- on the basis of the title and abstract. All studies
toms may do so. Therefore, treatment seems warranted. that specifically referred to the alcohol hangover
were included in the data analysis. A formal meta-
Conclusions: Hangover, a common disorder, has sub-
stantial morbidity and societal cost. Appropriate manage- analysis was not performed because the few clinical
ment may relieve symptoms in many patients. trials were not similar in design or hypotheses.
Definition
Hormone and Electrolytes Affected (Reference) Acute Alcohol Intoxication Hangover Effect Proportional to
Hangover Severity
The ways in which hangover affects total alcohol of those who consumed the same dose of vodka
consumption are not clearly understood. Many per- (which has low congeners) experienced severe hang-
sons believe that hangover is a punishment for al- over (41).
cohol consumption and therefore prevents subse- The constellation of hangover symptoms (nausea,
quent alcohol use (34). Hangover has never been headache, diarrhea) resembles that seen in condi-
shown to effectively deter alcohol consumption, tions related to dysregulated cytokine pathways (for
however, and no evidence shows that alleviation of example, in viral infections and after administration
hangover symptoms would result in further con- of interferon-). Alcohol alters cytokine production
sumption (34). In contrast, the discomfort of hang- through a thromboxane pathway. Levels of throm-
over symptoms may prompt further alcohol intake boxane B2 are elevated during experimentally in-
(for example, the eye opener). One study of 178 duced alcohol hangover (42), and the administration
persons found that those who experience greater of tolfenamic acid, a prostaglandin inhibitor, at the
hangover may choose to drink more alcohol in or- time of alcohol consumption has a small prophylac-
der to relieve these adverse effects (35). Therefore, tic effect in reducing hangover severity (9).
successful treatment of hangover could mitigate to- Several hormonal alterations have been observed
tal alcohol consumption. in patients with hangover (43 45) (Table 3). Hang-
over severity is proportional to antidiuretic hormone
Physiologic and Clinical concentration (46). Alcohol inhibits the effect of
Manifestations of Hangover antidiuretic hormone on the kidneys, thereby induc-
ing diuresis that is out of proportion to the volume
Part of the mystery of hangover is the set of ill-
of fluid ingested. As blood alcohol concentration
defined physiologic characteristics that underlie the
syndrome. One theory is that hangover is the first decreases and dehydration persists, the serum level
stage of alcohol withdrawal. However, the hormonal of antidiuretic hormone increases, maintaining wa-
and hemodynamic changes seen in hangover are ter retention in dehydrated patients with hangover.
distinct from those seen in alcohol withdrawal In our clinical experience, hydration attenuates but
(Table 2). does not completely relieve hangover symptoms. Se-
Although larger doses of alcohol lead to more rum aldosterone and renin levels also increase with
severe symptoms, hangover is not solely dose- hangover, but unlike antidiuretic hormone, they do
related (37). Acetaldehyde, the dehydrogenated not correlate well with hangover severity (47, 48).
product of alcohol metabolism (38), might be re- The effect of alcohol consumption and hangover
sponsible for hangover symptoms (10). Congeners, on glucose metabolism is incompletely understood.
the byproducts of individual alcohol preparations Alcohol seems to inhibit the availability of glucose
(which are found primarily in brandy, wine, tequila, through an insulin-mediated mechanism (49). Glu-
whiskey, and other dark liquors), increase the fre- cagon is increased in acute alcohol intoxication, but
quency and severity of hangover (24, 39, 40). Clear its effect during hangover is unknown (50). Cortisol
liquors, such as rum, vodka, and gin, tend to cause release is also suppressed during acute alcohol in-
hangover less frequently, which may explain why toxication, but this effect does not persist in hang-
patients with chronic alcoholism use these liquors over (51). Levels of thyroid (44, 52) and growth
disproportionately. In an experimental setting, 33% hormone (52) do not change during acute alcohol
of patients who consumed 1.5 g/kg of body weight intoxication or hangover. Both acute intoxication
of bourbon (which has high congeners) but only 3% and hangover cause metabolic acidosis (53, 54).
6 June 2000 Annals of Internal Medicine Volume 132 Number 11 899