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Hangover
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A hangover /ˈhæŋoʊvər/ (medical terminology: veisalgia) is the experience of various unpleasant physiological effects following heavy consumption of alcoholic beverages. The most commonly reported characteristics of a hangover include headache, nausea, sensitivity to light and noise, lethargy, dysphoria, diarrhea and thirst, typically after the intoxicating effect of the alcohol begins to wear off. While a hangover can be experienced at any time, generally a hangover is experienced the morning after a night of heavy drinking. In addition to the physical symptoms, a hangover may also induce psychological symptoms including heightened feelings of depression and anxiety.

Hypoglycemia, dehydration, acetaldehyde intoxication and glutamine rebound are all theorized causes of hangover symptoms.[1] Hangover symptoms may persist for several days after alcohol was last consumed. 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 from two electrodes implanted in the lateral hypothalamus) following ethanol injection.[2]

Causes

Hangovers are caused by several factors. First, the body has to metabolize the active ingredient in alcoholic beverages: ethanol. This process requires cellular energy, distracting the body from normal activities like making glucose for the brain. Even after all the ethanol is metabolized, the by-products of this process can cause additional problems. Likewise, other substances in certain alcoholic beverages can make a hangover worse. Lastly, ethanol is a diuretic and can lead to dehydration.

Metabolism

After being ingested, ethanol is first converted to acetaldehyde by the enzyme alcohol dehydrogenase and then to acetic acid by oxidation process. These reactions also convert NAD+ to NADH. However, by causing a shortage of NAD+ and an excess of NADH, alcoholic beverages make normal bodily functions more difficult. For example, excess NADH causes the important citric acid cycle to shut down by inhibiting three important enzymes (citrate synthase, isocitrate dehydrogenase, and alpha-ketoglutarate dehydrogenase).

To correct this imbalance the body uses pyruvate and lactate dehydrogenase to convert the excess NADH back into NAD+. In the process, however, the body diverts pyruvate from other important pathways such as gluconeogenesis. This impairs the ability of the liver to compensate for a drop in blood glucose levels, especially for the 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.[citation needed]

Alcohol consumption can result in depletion of the liver's supply of glutathione[3] and other reductive detoxification agents,[4] 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.[5]

By-products of ethanol

Acetaldehyde, the first by-product of ethanol, is between 10 and 30 times more toxic than alcohol itself.[6] In addition, certain genetic factors can amplify the negative effects of acetaldehyde. For example, East Asian people have a mutation in their alcohol dehydrogenase gene that makes this enzyme unusually fast at converting ethanol to acetaldehyde. In addition, about half of all East Asians convert acetaldehyde to acetic acid more slowly (via acetaldehyde dehydrogenase), causing a higher build up of acetaldehyde than normally seen in other groups.[7] The high concentration of acetaldehyde causes the alcohol flush reaction, colloquially known as the "Asian Glow". Since the alcohol flush reaction is highly uncomfortable and the possibility of hangovers is immediate and severe, East Asians are less likely to become alcoholics.[8][9]

Although not scientifically documented, there are reports that consuming certain antacids or Brewer's yeast before drinking can decrease in the alcohol flush reaction.

Likewise, acetic acid (or the acetate ion) can cause additional problems. One study found that injecting sodium acetate into rats caused them to have nociceptive behavior (headaches). In addition, there is a biochemical explanation for this finding. High acetate levels cause adenosine to accumulate in many parts of the brain. But when the rats were given caffeine, which blocks the action of adenosine, they no longer experienced headaches.[10][11][12][13]

Congeners

In addition to ethanol and water, most alcoholic drinks also contain congeners, either as flavoring or as a by-product of fermentation. However, different types of alcohol contain different amounts of congeners. In general, dark liquors have a higher concentration while clear liquors have a lower concentration.

Several studies have examined whether certain types of alcohol cause worse hangovers.[14][15][16][17] All four studies concluded that darker liquors, which have higher congeners, produced worse hangovers. One even showed that hangover were worse and more frequent with darker liquors.[14] In a 2006 study, an average of 14 standard drinks (330 ml) of beer was needed to produce a hangover, but only 7 to 8 drinks was required for wine or liquor (note that beers contains 4 to 8% alcohol by volume whereas wine is ca. 13% and Liquors 40 to 50%).[17] Another study ranked several drinks by their ability to cause a hangover (from low to high): distilled ethanol diluted with fruit juice, beer, vodka, gin, white wine, whisky, rum, red wine and brandy.[16][17] While congeners do cause hangovers(note their conclusions are not based on valid scientific inquiry), they do not affect how drunk the person becomes.[15]

One potent congener is methanol. It is naturally formed in small quantities during fermentation and it can be accidentally concentrated by improper distillation techniques. Metabolism of methanol produces an extremely toxic compound, formaldehyde; however, its metabolism is suppressed when ethanol is present in the bloodstream. Therefore, methanol is a likely cause of hangovers that begin when the person's blood alcohol level approaches zero. Incidentally, these hangovers can be "cured" by consuming more ethanol.

Dehydration and age

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 before, during and after consumption of alcohol. Alcohol's effect on the stomach lining can account for nausea.[citation needed] In addition, 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.[18]

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 and heart rate, 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 significantly from person to person, and it is not clear whether hangovers directly affect cognitive abilities.

Research

Psychological research of alcohol hangover is growing rapidly. The Alcohol Hangover Research Group had its inaugural meeting in June 2010 as part of the Research Society on Alcoholism (RSA) 33rd Annual Scientific Meeting in San Antonio, Texas.

In 2010, researchers from the Centre for Alcohol and Drug Research at the University of Aarhus in Copenhagen charted how hangovers progress over time in the face of continued drinking. They found no evidence of hangover tolerance. Instead, they found that hangover symptoms became steadily worse over the course of one week.[19]

In 2012, Éduc'alcool, a Quebec-based non-profit organization that aims to educate the public on the responsible use of alcohol, published a report noting hangovers have long-lasting effects that inhibit the drinker's capabilities a full 24 hours after heavy drinking.[20]

Possible remedies

Hangovers are poorly understood from a medical point of view.[21] Health care professionals prefer to study alcohol abuse from a standpoint of treatment and prevention, and there is a view that the hangover provides a useful, natural and intrinsic disincentive to excessive drinking.[22]

Within the limited amount of serious study on the subject, there is debate about whether a hangover may be prevented or at least mitigated; additionally, there is a vast body of 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 other than waiting for the body to metabolize ingested alcohol, which occurs via oxidation through the liver before alcohol leaves the body. A four-page literature review in the British Medical Journal 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."[23]

Potentially beneficial remedies

  • Rehydration: "Effective interventions include rehydration, prostaglandin inhibitors, and vitamin B6".[24]
  • Tolfenamic acid (TA): A study concludes that "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)."[25]
  • Vitamin B6 (pyritinol): Some studies have found large doses of Vitamin B6 (several hundred times the recommended daily intake) can help to reduce hangovers.[24][26] As it happens, brewers' yeast supplements are reasonably high in Vitamin B6.[1]
  • 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."[27] "However, all 8 subjects had unpleasant nasal symptoms following chlormethiazole, and it is therefore not an ideal hypnotic for this age group."[28]
  • Opuntia ficus-indica: An extract of Opuntia ficus indica has been found to reduce the effects of hangover. "The severity of the alcohol hangover may be related to inflammation induced by impurities in the alcohol beverage and byproducts of alcohol metabolism. An extract of the Opuntia ficus indica (OFI) plant diminishes the inflammatory response to stressful stimuli." [29]
  • Pedialyte: Pedialyte may be an effective remedy for hangovers due to its replacement of lost electrolytes. Sports drinks, such as Gatorade, may also benefit in a similar manner.
  • Hair of the dog: The belief that consumption of further alcohol after the onset of a hangover will relieve symptoms, based upon the theory that the hangover represents a form of alcohol withdrawal[22] and that by satiating the body's need for alcohol the symptoms will be relieved. Certainly the additional alcohol has a sedating and anaesthetic effect.[30] While the practice is affirmed by tradition[31] and by many hospitality providers,[32] medical opinion holds that the practice merely postpones the symptoms, and courts addiction.[33] Favored choices include Fernet Branca[34] and Bloody Mary.[30]
  • Yeast-based extracts: There is some evidence that the consumption of a yeast-based extract rich in thiamine and riboflavin (such as Vegemite or Marmite) is effective in the relief of hangover symptoms.[23] These extracts are commonly manufactured from a by-product of beer production.
  • 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. Researchers have found that beef noodle soup "Yaka mein" commonly found in New Orleans work as an effective cure for hangovers.[35] A traditional hangover remedy in India is coconut water, the natural electrolytes of which will assist in rehydration of the body. A bacon sandwich has also been claimed to effectively relieve hangovers,.[36] 2M2B, another higher alcohol, occurs in fried bacon.[37] Fruit juice has been reported to alleviate some of the symptoms.[2]
  • Oxygen: 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.[38] However, one source states that (in an aviation context) oxygen has no effect on physical impairment caused by hangover.[39]
  • Rosiglitazone: [Study in rats] "Rosiglitazone alleviated the symptoms of ethanol-induced hangover by inducing ALD2 expression..."[40]
  • Acetylcysteine: There are claims that N-acetylcysteine can relieve or prevent symptoms of hangover through scavenging of acetylaldehyde, particularly when taken concurrently with alcohol.[41] Additional reduction in acetaldehyde toxicity can be achieved if NAC is taken in conjunction with vitamin B1 (thiamine).[6]
  • Acétyl-leucine: Sold under the brand name of Tanganil, this is the standard remedy prescribed to people suffering from chronic vertigo, and so may lessen the "whirling pit" effect of a hangover, where there is a dysfunction between the nerves which control the notion of balance in the ears and the brain.[citation needed]
  • Cannabis: It is commonly believed that THC, the main psychoactive chemical in cannabis, is an effective hangover remedy. THC may help ease the main symptoms of hangovers: nausea and headache. The advantage is two-fold; as once a sufferer's nausea has abated, and his/her appetite is stimulated, hypoglycemia becomes easier to resolve.[42]

Ineffective or unproven remedies

Recommendations for foods, drinks and activities to relieve hangover symptoms abound. The ancient Romans, on the authority of Pliny the Elder, favored raw owl's eggs or fried canary,[43] while the "Prairie Oyster" restorative, introduced at the 1878 Paris World Exposition, calls for raw egg yolk mixed with Worcestershire sauce, Tabasco sauce, salt and pepper.[44] By 1938, the Ritz-Carlton Hotel provided a hangover remedy in the form of a mixture of Coca-Cola and milk[44] (Coca-Cola itself having been invented, by some accounts,[45][46] as a hangover remedy). Alcoholic writer Ernest Hemingway relied on tomato juice and beer.[47] Certain mixtures were developed specifically for the purpose. The "Black Velvet" consists of equal parts champagne and flat Guinness Stout,[47] A 1957 survey by a Wayne State University folklorist found widespread belief in the efficacy of heavy fried foods, tomato juice and sexual activity.[31]

Activities said to be restorative include a shower—alternating very hot and very cold water,[48] exercise,[49][unreliable source?] and steambath or sauna (although medical opinion holds this to be very dangerous, as the combination of alcohol and hyperthermia increases the likelihood of dangerous cardiac arrhythmias).[50]

Other untested or discredited treatments include:

  • Globe artichoke (Cynara scolymus) extract: "Our results suggest that artichoke extract is not effective in preventing the signs and symptoms of alcohol-induced hangover."[51]
  • Propranolol: "We conclude that propranolol does not prevent the symptoms of hangover."[52][53]
  • 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."[54] Nevertheless, consumption of honey (a significant fructose and glucose source) is often suggested as a way to reduce the effect of hangovers.[55]
  • Kudzu (Pueraria montana var. lobata): The main ingredient in remedies such as kakkonto. 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."[56]

See also

References

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