Hangovers

Why do they happen and what is the best cure? David Lucey indulges, for your education of course

Your eyes open slowly, and you realise you're wearing someone else's underpants over your trousers. It's half an hour after the start of the microbiology tutorial you promised yourself you would go to, after you missed it the week before. You feel like something angry has ravished your head and died in your mouth. You don't congratulate yourself on the self-diagnosis of a hangover, also known as veisalgia (from the Norwegian “kveis”, meaning “uneasiness following debauchery,” and the Greek “algos,” meaning “pain”).

What causes this to happen? What occurs between the time you are swigging triple whiskeys and chatting up a barstool, and the following barrage of mini-explosions in your head?

Surprisingly, ethanol itself may only be a minor player in generating the nausea, sweating, tremor, thirst, headache, fatigue, remorse, and anxiety that hangover sufferers report. The fact that symptoms are at maximum severity when virtually all of the ethanol and its metabolite acetaldehyde have been cleared from the bloodstream is evidence for this. In addition, peak blood concentrations of ethanol or acetaldehyde do not correlate with the severity of hangover.

The formation of formaldehyde and formic acid from the breakdown of methanol is thought to be the true culprit of hangover symptoms. People who metabolise methanol faster suffer more. This is argued on the basis that those drinks associated with more severe hangovers contain higher concentrations of methanol and that the time course of methanol metabolism corresponds to the onset of symptoms.

In addition, a small dose of ethanol, which blocks the formation of formaldehyde and formic acid, provides an effective treatment for hangovers: the “hair of the dog.”

Congeners are byproducts of the production of spirits or wines. They are complex organic molecules such as polyphenols, including histamine and methanol, and give the drink a distinct flavour. Having drinks that contain more congeners increase both the frequency and severity of hangovers. Hence, your choice of drink can have an effect too (box 1).

Cheap spirits (especially cheap whisky) and champagnes are among the worst offenders(BBC News, Hangovers: The number one festive illness, BBC1 24 Dec, 1998. Interview with Dr James Schaefer, a research professor at the department of anthropology at Union College in Schenectady, New York). Clear liquors such as gin, vodka, and rum cause hangovers less often, having usually been distilled three or four times, which may help explain why they are abused to a greater extent by chronic alcoholics.

The severity of hangover symptoms diminishes in the order of brandy, red wine, rum, whisky, white wine, gin, vodka, and pure ethanol, according to one study.

Only two volunteers in that study (n=20) experienced mild headaches after drinking pure ethanol (whooah!) or vodka. Another experimental study showed that people who drank 1.5 ml/kg of bourbon whiskey (methanol concentrations of 26 mg/l) had almost double the probability of experiencing hangover symptoms compared with volunteers drinking the same dose of vodka (3.9 mg of methanol per litre). Pain may also come after red wine because it contains tyramine, a substance known to cause severe headaches.

Many physiological disturbances occur during hangover, including dehydration; metabolic acidosis; hypoglycaemia; disturbed prostaglandin synthesis; abnormal secretion of vasopressin, cortisol, aldosterone, renin, and testosterone; increased cardiac output; tachycardia; and vasodilatation.

Oddly enough, your frame of mind while you drink is a better predictor of hangover symptoms than the amount of ethanol you drink. A study found that factors such as a negative life event in the preceding 12 months, having a neurotic personality, or becoming depressed or angry while drinking can make it more likely that your head will hurt the morning after.

There are some who would subscribe to the decidedly nihilistic panacea of the “hair of the dog,” favoured by comedian W C Fields, who said “another drink, only stronger than last night's.” Jones showed this to be a somewhat effective remedy for reasons given above. Reason enough to veer away from this slippery downhill slope is that the “E” in the CAGE screening for alcoholism stands for “eye opener.”

Aspirin should be avoided because of the potential for gastric irritation, and paracetamol can be toxic to the liver after drinking large quantities of alcohol. A compromise is to choose remedies that are absorbed quickly and therefore less likely to irritate the stomach, such as Alka Seltzer. That said, combining anti-inflammatory analgesics with rehydration will help recovery, especially if treatment is started before bedtime.

Alcohol is a diuretic so avoid dehydration by drinking as much water as you can, preferably more by volume than the alcoholic drinks you've had.

Prophylactic vitamin B6 (pyrinitol) halved the number of hangover symptoms in one study. Participants went to two parties and were instructed to get intoxicated on the tipple of their choice. Half the volunteers were given 400 mg at the beginning of one party, then three hours later, and finally at the party's conclusion. The other half received a placebo. The regimen was swapped at the second party.

Prostaglandin inhibitors such as tolfenamic acid have also been shown to reduce hangover symptoms.

The hangover is a complicated condition that has yet to be fully elucidated. There is no perfect cure for hangovers, except abstinence. Seriously though, many things can be done during and after consumption to limit the after effects (see box). In spite of the scarcity of research funds, this author will continue in his active quest for the truth.

Hangover prevention and cure

• Drink water between rounds (more than equivalent)
• Prophylactic vitamin B6 (pyritinol) 400mg at the beginning, middle and end of party
• Avoid drinks with a high congener concentration such as tequila, wine and whiskey
• Don't exert yourself too much when drinking
• Keep yourself in good physical health.

David Lucey, fifth year medical student, University College Dublin
Email: davelucey@hotmail.com


studentBMJ 2002;10:171-214 June ISSN 0966-6494

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