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Hangover
Classification and external resources

"The Hangover" (portrait of Suzanne Valadon, by Toulouse-Lautrec)
ICD-10 G44.83, F10

A hangover (pronounced /ˈhæŋoʊvər/) (veisalgia) or delayed alcohol induced headache describes the sum of unpleasant physiological effects following heavy consumption of alcoholic beverages. The most commonly reported characteristics of a hangover include headache, sensitivity to light and noise, lethargy, dysphoria, diarrhea and thirst. A hangover may also induce psychological symptoms including heightened feelings of depression and anxiety.

Hypoglycemia, dehydration, acetaldehyde intoxication, and vitamin B12 deficiency are all theorized causes of hangover symptoms. Hangover symptoms may persist for several days after alcohol was last consumed. Approximately 25-30% of drinkers may be resistant to hangover symptoms.[1] Some aspects of a hangover are viewed as symptoms of acute ethanol withdrawal, similar to the longer-duration effects of withdrawal from alcoholism, as determined by studying the increases in brain reward thresholds in rats (the amount of current required to receive to electrodes implanted in the lateral hypothalamus) following ethanol injection.[2] Dehydration is caused by the simple osmotic effect of alcohol in the blood drawing water out of the tissues and into the blood, and from there into the kidneys.

Contents

Etymology

The term hangover was originally a 19th century expression describing unfinished business—something left over from a meeting—or "survival." In 1904, the meaning "morning after-effect of drinking too much" first surfaced.[3][4]

Symptoms

An alcohol hangover is associated with a variety of symptoms that may include dehydration, fatigue, headache, body aches, vomiting, diarrhea, flatulence, weakness, elevated body temperature, hypersalivation, difficulty concentrating, sweating, anxiety, dysphoria, irritability, sensitivity to light and noise, erratic motor functions (including tremor), trouble sleeping, severe hunger, halitosis, and lack of depth perception. Many people will also be repulsed by the thought, taste or smell of alcohol during a hangover. The symptoms vary from person to person, and occasion to occasion, usually beginning several hours after drinking. It is not clear whether hangovers directly affect cognitive abilities.

Causes

Ethanol has a dehydrating effect by causing increased urine production (diuresis), which causes headaches, dry mouth, and lethargy. Dehydration also causes fluids in the brain to be less plentiful. This can be mitigated by drinking water after consumption of alcohol. Alcohol's effect on the stomach lining can account for nausea.

Another contributing factor is the presence of products from the breakdown of ethanol by liver enzymes. Ethanol is converted to acetaldehyde by the enzyme alcohol dehydrogenase, and then from acetaldehyde to acetic acid by the enzyme acetaldehyde dehydrogenase. Acetaldehyde (ethanal) is between 10 and 30 times more toxic than alcohol itself,[5] as well as being cocarcinogenic (not carcinogenic solely by itself) and mutagenic.[6]

These two reactions also require the conversion of NAD+ to NADH. With an excess of NADH, three enzymes of the Citric Acid Cycle are inhibited (citrate synthase, isocitrate dehydrogenase, and alpha-ketoglutarate dehydrogenase) essentially shutting it down. Pyruvate (the end product of glycolysis) starts to accumulate, and the excess NADH drives lactate dehydrogenase to produce lactate from pyruvate in order to regenerate NAD+ and sustain life. This diverts pyruvate from other pathways such as gluconeogenesis, thereby impairing the ability of the liver to compensate for a drop in blood glucose levels, especially for brain. Because glucose is the primary energy source of the brain, this lack of glucose (hypoglycemia) contributes to symptoms such as fatigue, weakness, mood disturbances, and decreased attention and concentration.

Alcohol consumption can result in depletion of the liver's supply of glutathione[7] and other reductive detoxification agents,[6] reducing its ability to effectively remove acetaldehyde and other toxins from the bloodstream. Additionally, alcohol induces the CYP2E1 enzyme, which itself can produce additional toxins and free radicals.[8]

In addition, it is thought that the presence of other alcohols (such as fusel oils), by-products of the alcoholic fermentation also called congeners, exaggerate many of the symptoms (congeners may also be zinc or other metals added primarily to sweet liqueurs to enhance their flavor); this probably accounts for the mitigation of the effects when distilled alcohol, particularly vodka, is consumed instead.[9] A 2009 study provided evidence that darker-coloured liquors, such as bourbon, cause worse hangovers than lighter-coloured liquors, such as vodka. The higher amount of congeners found in darker liquors compared to lighter ones was indicated as the cause.[10]

Most people of East Asian descent have a mutation in their alcohol dehydrogenase gene that makes this enzyme unusually effective at converting ethanol to acetaldehyde, and about half of such people also have a form of acetaldehyde dehydrogenase that is less effective at converting acetaldehyde to acetic acid.[11] This combination causes them to suffer from alcohol flush reaction, in which acetaldehyde accumulates after drinking, leading to immediate and severe hangover symptoms. These people are therefore less likely to become alcoholics.[12][13]

It is often said that hangovers grow worse as one ages; this is thought to be caused by declining supplies of alcohol dehydrogenase, the enzyme involved in metabolizing alcohol.[8]

Possible remedies

Hangovers are poorly understood from a medical point of view. Health care professionals prefer to study alcohol abuse from a standpoint of treatment and prevention, and there is a view that reducing the disincentives to excess drinking might encourage it.[14]

There is debate about whether a hangover might be prevented or at least mitigated, along with much folk medicine and simple quackery. There is currently no empirically proven mechanism for prevention except reducing the amount of ethanol consumed, or for making oneself sober short of waiting for the body to metabolize ingested alcohol, which occurs via oxidation through the liver before alcohol leaves the body. The consumption of fluids can also rid the body of reminiscent alcohol and improve mood.

A four-page literature review in British Medical Journal on hangover remedies by Max Pittler of the Peninsula Medical School at Exeter University and colleagues concludes: "No compelling evidence exists to suggest that any conventional or complementary intervention is effective for preventing or treating alcohol hangover. The most effective way to avoid the symptoms of alcohol induced hangover is to avoid drinking."[15]

Ineffective or unproven remedies

The "Prairie Oyster" restorative, introduced at the 1878 Paris World Exposition consisted of raw egg yolk mixed with Worcestershire sauce, Tabasco sauce, salt and pepper. [16] Other untested or discredited treatments include:

  • Hair of the dog: The belief that consumption of further alcohol after the onset of a hangover is a viable treatment of the symptoms. Some say that this is based upon the theory that hangover symptoms are likened to withdrawal symptoms and that by satiating the body's need for alcohol they will be assuaged. Certainly the additional alcohol has a sedating and anaesthetic effect.[17] While the practice is affirmed by tradition[18] and by many hospitality providers[19] medical opinion holds that the practice merely postpones the symptoms, and courts addiction. [20] Favored choices include Fernet Branca,[21] Bloody Mary[22]
  • Globe artichoke (Cynara scolymus) extract: "Our results suggest that artichoke extract is not effective in preventing the signs and symptoms of alcohol-induced hangover."[23]
  • Propranolol: "We conclude that propranolol does not prevent the symptoms of hangover."[24][25]
  • Fructose and glucose: A 1976 research came to the conclusion that "The results indicate that both fructose and glucose effectively inhibit the metabolic disturbances induced by ethanol but they do not affect the symptoms or signs of alcohol intoxication and hangover."[26] Nevertheless, consumption of honey (a significant fructose and glucose source) is often suggested as a way to reduce the effect of hangovers.[27]
  • Kudzu (Pueraria montana var. lobata): A study concluded, "The chronic usage of Pueraria lobata at times of high ethanol consumption, such as in hangover remedies, may predispose subjects to an increased risk of acetaldehyde-related neoplasm and pathology. ... Pueraria lobata appears to be an inappropriate herb for use in herbal hangover remedies as it is an inhibitor of ALDH2."[28]

Potentially beneficial remedies

  • Food and water: consumption of foods such as eggs, which contain cysteine, and water may be enough to replenish lost moisture and at least rehydrate the body, making a hangover shorter. A bacon, egg and cheese sandwich has also been claimed to effectively relieve hangovers.[29]
  • Rehydration: "Effective interventions include rehydration, prostaglandin inhibitors, and vitamin B6".[30]
  • Oxygen: In a double-blind random study of 231 patients at two Vienna hospitals, published in Anesthesiology in 1999 and reported by The New York Times, it was found that the side-effects of general anesthesia could be diminished by giving patients a mix of 80 percent oxygen and 20 percent nitrogen during the surgery, and for two hours afterward. Only 17 percent of the patients receiving supplemental oxygen experienced nausea and vomiting, compared with 30 percent of the group who were given the standard 30 percent oxygen and 70 percent nitrogen.[31] The study's leader characterized the results for the Times, "Extra oxygen is cheap, risk-free and reduces the incidence of nausea as well as any known drug." A related study by members of Dr. Sessler's team, published in Anesthesiology in October 1999, indicated that patients given oxygen in amounts up to 80 percent did not suffer impaired lung function. In addition, there have been anecdotal reports from those with easy access to a breathing oxygen supply — medical staff, SCUBA divers and military pilots — that oxygen can also reduce the symptoms of hangovers sometimes caused by alcohol consumption. The theory is that the increased oxygen flow resulting from oxygen therapy improves the metabolic rate, and thus increases the speed at which toxins are broken down.[32] However, one source states that (in an aviation context) oxygen has no effect on physical impairment caused by hangover.[33]
  • Tolfenamic acid (TA): A study concludes, "TA was found significantly better than placebo in the subjective evaluation of drug efficacy (p < 0.001) and in reducing the reported hangover symptoms in general (p < 0.01). In the TA group, significantly lower symptom scores were obtained for headache (p < 0.01), and for nausea, vomiting, irritation, tremor, thirst, and dryness of mouth (all p < 0.05)."[34]
  • Vitamin B6 (pyritinol): Some studies have found large doses of Vitamin B6 (several hundred times the recommended daily intake) can help to reduce hangovers.[30][35]
  • Chlormethiazole: "Chlormethiazole was found to lower blood pressure and adrenaline output and, furthermore, to relieve unpleasant physical symptoms, but did not affect fatigue and drowsiness. The cognitive test results were only slightly influenced by this agent, while psychomotor performance was significantly impaired. Subjects with severe subjective hangover seemed to benefit more from the chlormethiazole treatment than subjects with a mild hangover."[36] "However, all 8 subjects had unpleasant nasal symptoms following chlormethiazole, and it is therefore not an ideal hypnotic for this age group."[37]
  • Rosiglitazone: [Study in rats] "Rosiglitazone alleviated the symptoms of ethanol-induced hangover by inducing ALD2 expression..."[38]
  • Acetylcysteine: There are claims that N-acetylcysteine can relieve or prevent symptoms of hangover through scavenging of acetylaldehyde, particularly when taken concurrently with alcohol.[39][40] Additional reduction in acetaldehyde toxicity can be achieved if NAC is taken in conjunction with vitamin B1 (thiamine).[5]

See also

References

  1. ^ Howland J, Rohsenow DJ, Allensworth-Davies D, et al. (May 2008). "The incidence and severity of hangover the morning after moderate alcohol intoxication". Addiction 103 (5): 758–65. doi:10.1111/j.1360-0443.2008.02181.x. PMID 18412754. http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0965-2140&date=2008&volume=103&issue=5&spage=758. 
  2. ^ Schulteis G, Liu J (May 2006). "Brain reward deficits accompany withdrawal (hangover) from acute ethanol in rats". Alcohol 39 (1): 21–8. doi:10.1016/j.alcohol.2006.06.008. PMID 16938626. PMC 2266583. http://linkinghub.elsevier.com/retrieve/pii/S0741-8329(06)00106-6. 
  3. ^ "Hangover: Online Etymology Dictionary". Etymonline.com. http://www.etymonline.com/index.php?term=hangover. Retrieved 2009-10-18. 
  4. ^ "Frank Kelly Rich: On the Cuff & Under the Table: The Origins and History of Drinking Words and Phrases (Modern Drunkard Magazine 2008)". Drunkard.com. http://drunkard.com/issues/02_05/02-05_on_the_cuff.htm. Retrieved 2009-10-18. 
  5. ^ a b Sprince H, Parker CM, Smith GG, Gonzales LJ (April 1974). "Protection against acetaldehyde toxicity in the rat by L-cysteine, thiamin and L-2-methylthiazolidine-4-carboxylic acid". Agents Actions 4 (2): 125–30. doi:10.1007/BF01966822. PMID 4842541. http://www.springerlink.com/content/w307w62037125v33/. 
  6. ^ a b Stickel F, Schuppan D, Hahn EG, Seitz HK (July 2002). "Cocarcinogenic effects of alcohol in hepatocarcinogenesis". Gut 51 (1): 132–9. doi:10.1136/gut.51.1.132. PMID 12077107. PMC 1773267. http://gut.bmj.com/cgi/content/full/51/1/132. 
  7. ^ Kera Y, Ohbora Y, Komura S (1989). "Buthionine sulfoximine inhibition of glutathione biosynthesis enhances hepatic lipid peroxidation in rats during acute ethanol intoxication". Alcohol Alcohol. 24 (6): 519–24. PMID 2576368. http://alcalc.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=2576368. 
  8. ^ Kessova I, Cederbaum AI (September 2003). "CYP2E1: biochemistry, toxicology, regulation and function in ethanol-induced liver injury". Curr. Mol. Med. 3 (6): 509–18. doi:10.2174/1566524033479609. PMID 14527082. http://www.bentham-direct.org/pages/content.php?CMM/2003/00000003/00000006/0004M.SGM. 
  9. ^ Wiese JG, Shlipak MG, Browner WS (6 June 2000). "The alcohol hangover". Ann. Intern. Med. 132 (11): 897–902. PMID 10836917. http://www.annals.org/cgi/content/full/132/11/897. 
  10. ^ 8:32 p.m. ET (2009-12-18). "Whiskey hangover worse than vodka, study says - Behavior- msnbc.com". MSNBC. http://www.msnbc.msn.com/id/34485233/ns/health-behavior/. Retrieved 2010-02-03. 
  11. ^ Xiao Q, Weiner H, Crabb DW (1996). "The mutation in the mitochondrial aldehyde dehydrogenase (ALDH2) gene responsible for alcohol-induced flushing increases turnover of the enzyme tetramers in a dominant fashion". J. Clin. Invest. 98 (9): 2027–32. doi:10.1172/JCI119007. PMID 8903321. PMC 507646. http://www.jci.org/cgi/content/abstract/98/9/2027. 
  12. ^ Earleywine, Mitchell (1999). Mind-Altering Drugs: The Science of Subjective Experience. OUP USA. p. 163. ISBN 978-0195165319. 
  13. ^ "Alcohol Metabolism in Asian-American Men with Genetic Polymorphisms of Aldehyde Dehydrogenase — Ann Intern Med". Annals.org. 1997-09-01. http://www.annals.org/cgi/content/full/127/5/376. Retrieved 2010-02-03. 
  14. ^ [1]
  15. ^ Pittler MH, Verster JC, Ernst E (December 2005). "Interventions for preventing or treating alcohol hangover: systematic review of randomized controlled trials". BMJ 331 (7531): 1515–8. doi:10.1136/bmj.331.7531.1515. PMID 16373736. PMC 1322250. http://bmj.bmjjournals.com/cgi/content/full/331/7531/1515. 
  16. ^ [2]
  17. ^ [3]
  18. ^ A Hair of the Dog and Some Other Hangover Cures from Popular Tradition Frank M. Paulsen The Journal of American Folklore, Vol. 74, No. 292 (Apr. - Jun., 1961), pp. 152-168
  19. ^ http://articles.sfgate.com/2006-12-29/wine/17324420_1_hangover-bloody-mary-drinking]
  20. ^ [4]
  21. ^ [5]
  22. ^ [6]
  23. ^ Max H. Pittler, Adrian R. White, Clare Stevinson and Edzard Ernst Effectiveness of artichoke extract in preventing alcohol-induced hangovers: a randomized controlled trial CMAJ December 9, 2003; 169 (12)
  24. ^ Bogin RM, Nostrant TT, Young MJ (1986). "Propranolol for the treatment of the alcoholic hangover". Am J Drug Alcohol Abuse 12 (3): 279–84. doi:10.3109/00952998609007397. PMID 3503570. 
  25. ^ Bogin RM, Nostrant TT, Young MJ (1987). "Propranolol for the treatment of the alcoholic hangover". Am J Drug Alcohol Abuse 13 (1-2): 175–80. doi:10.3109/00952998709001507. PMID 3318398. 
  26. ^ Ylikahri RH, Leino T, Huttunen MO, Pösö AR, Eriksson CJ, Nikkilä (January 1976). "Effects of fructose and glucose on ethanol-induced metabolic changes and on the intensity of alcohol intoxication and hangover". Eur. J. Clin. Invest. 6 (1): 93–102. doi:10.1111/j.1365-2362.1976.tb00498.x. PMID 1253812. 
  27. ^ "UMDNJ Experts Suggest Remedies for Holiday Headaches". Umdnj.edu. 2007-12-20. http://www.umdnj.edu/about/news_events/releases/07/r122007_UMDNJ_Expert_SuggestsHoney.htm. Retrieved 2009-10-18. 
  28. ^ McGregor NR (November 2007). "Pueraria lobata (Kudzu root) hangover remedies and acetaldehyde-associated neoplasm risk". Alcohol 41 (7): 469–78. doi:10.1016/j.alcohol.2007.07.009. PMID 17980785. http://linkinghub.elsevier.com/retrieve/pii/S0741-8329(07)00137-1. 
  29. ^ Telegraph.co.uk [7] 2009;
  30. ^ a b Wiese JG, Shlipak MG, Browner WS (June 2000). "The alcohol hangover". Ann. Intern. Med. 132 (11): 897–902. PMID 10836917. http://www.annals.org/cgi/content/full/132/11/897. 
  31. ^ Dr. Daniel Sessler Extra Oxygen for Anesthesia's Hangover The New York Times 9 November 1999
  32. ^ Timothy Walker and Mary Fitzgerald A drinker's guide to hangovers The Independent 17 April 2007
  33. ^ Reihheart, Richard (2007). Basic Flight Physiology. McGraw-Hill Professional. p. 179. ISBN 0-7735-0801-5. 
  34. ^ S. Kaivola1, J. Parantainen, T. Österman and H. Timonen "Hangover headache and prostaglandins: Prophylactic treatment with tolfenamic acid". Cephalalgia 3: 31. March 1983. doi:10.1046/j.1468–2982.1983.0301031.x (inactive 2009-07-02). http://www.blackwell-synergy.com/links/doi/10.1046%2Fj.1468-2982.1983.0301031.x. 
  35. ^ Khan MA, Jensen K, Krogh HJ (December 1973). "Alcohol-induced hangover. A double-blind comparison of pyritinol and placebo in preventing hangover symptoms". Q J Stud Alcohol 34 (4): 1195–201. PMID 4588294. 
  36. ^ Myrsten AL, Rydberg U, Ideström CM, Lamble R (1980). "Alcohol intoxication and hangover: modification of hangover by chlormethiazole". Psychopharmacology (Berl.) 69 (2): 117–25. doi:10.1007/BF00427636. PMID 6779303. 
  37. ^ Castleden CM, George CF, Sedgwick EM (March 1979). "Chlormethiazole—no hangover effect but not an ideal hypnotic for the young". Postgrad Med J 55 (641): 159–60. doi:10.1136/pgmj.55.641.159. PMID 379841. 
  38. ^ Jung TW, Lee JY, Shim WS, et al. (2006). "Rosiglitazone relieves acute ethanol-induced hangover in Sprague-Dawley rats". Alcohol Alcohol. 41 (3): 231–5. doi:10.1093/alcalc/agl013. PMID 16554376. http://alcalc.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=16554376. 
  39. ^ Fawkes, SW CERI: Living with Alcohol Smart Drug News 1996 Dec 13
  40. ^ Ozaras R, Tahan V, Aydin S, Uzun H, Kaya S, Senturk H (April 2003). "N-acetylcysteine attenuates alcohol-induced oxidative stess in rats". World J. Gastroenterol. 9 (4): 791–4. PMID 12679934. http://www.wjgnet.com/1007-9327/9/791.asp. 

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