Hangover headache: Alcohol, hangover and delayed alcohol-induced headaches

The consequences of excessive alcohol consumption are a long-known phenomenon in human history. The painful repercussions are already described in the Bible in Isaiah 5:11: “Woe to those who rise early in the morning to make a fuss about drunkenness…”. However, the delayed effects of alcohol do not only cause pain. They lead to severe cognitive impairments, misjudgments, and a reduction in visual and auditory perception, resulting in significant difficulties in professional and social life. The dangerous effects of a hangover are already described in Greek mythology. According to Homer's Odyssey, Elpenor, a companion of Odysseus, drank too much wine one evening. He fell asleep drunkenly on the roof of Circe's house. In the morning, he was startled awake by the noise of his companions preparing for their journey to the underworld. Due to delayed alcohol-induced headaches, impaired visual spatial perception, and misjudgment of the situation, he failed to realize he was on the roof, startled awake, fell backwards, and died from a broken neck. All because of delayed alcohol-induced headaches.

The origin of the name "hangover" is not entirely clear. One explanation points to its connection with the term "catarrh," which colloquially refers to a complex of symptoms including headache, nausea, and a general feeling of illness. Another explanation is its association with the term "cat's lament," describing the miserable feeling after a binge. This reflects the painful, plaintive, nocturnal wailing of male cats in heat. In the student slang of Goethe's time, the term "vomiting lament" was used, aptly describing nausea, vomiting, a general feeling of illness, headache, and even regret and self-reproach for excessive alcohol consumption.

The following summarizes scientific findings from the last three decades regarding the causes and treatment of delayed alcohol-induced headaches. These findings suggest that alcohol hangovers involve cardiovascular, hormonal, psychomotor, and cognitive impairments. These can occur regardless of the quantity of alcohol consumed or the frequency of drinking.

universally accepted definition of hangover headache or the after-effects of alcohol, the scientific term being delayed alcohol-induced headache . Scientific studies have identified the following main symptoms: headache, diarrhea, loss of appetite, tremors, fatigue, lethargy, malaise, and nausea. Headache and a pronounced feeling of illness are the primary symptoms in approximately two-thirds of those affected. The International Headache Society classifies alcohol-induced headache under code 8.1.4 . It distinguishes two subgroups: immediate alcohol-induced headache (code 8.1.4.1) and delayed alcohol-induced headache (code 8.1.4.2).

Alcohol-induced headache occurs within three hours of consuming alcohol and subsides within 72 hours of stopping alcohol consumption. The headache is characterized by bilateral, throbbing pain that worsens with normal physical activity. The amount of alcohol that triggers an immediate headache varies considerably between individuals. In people who suffer from migraines, even a small amount is often sufficient.

Delayed alcohol-induced headache is far more common than immediate alcohol-induced headache. The internationally recognized term for this headache, formerly known as "hangover headache," is now "delayed alcohol-induced headache." This type of headache is characterized by headaches that develop within 5-12 hours after alcohol consumption. The headache typically subsides within 72 hours. The headache is usually bilateral, throbbing in nature, and is exacerbated by routine physical activity. Delayed alcohol-induced headache is one of the most common forms of secondary headache. Other symptoms include reduced work capacity, impaired cognitive function, spatial disorientation, and changes in blood flow and hormone metabolism. Symptoms vary considerably from person to person and from case to case. The most prominent symptoms are a delayed onset headache and a general feeling of illness after consuming alcohol.

Delayed alcohol-induced headaches have serious social and economic consequences. According to a British study, approximately $2 billion in lost work time due to delayed alcohol-induced headaches is incurred annually. Similar figures are found in other countries. The annual cost per employee due to delayed alcohol-induced headaches is estimated at approximately $2,000.

In Finland alone, more than 1 million days of sick leave are caused annually by delayed alcohol-induced headaches. Light to moderate alcohol consumption is the most frequent cause of this sick leave.

More than 54% of all alcohol-related problems in the workplace are caused by light alcohol consumption. Delayed alcohol-induced headaches are the most frequent cause of the negative consequences of alcohol consumption. Chronic alcohol consumption, on the other hand, accounts for only a small portion of the total economic costs associated with the consequences of alcohol.

The widespread prevalence of delayed alcohol-induced headaches is worrying. Among students, 25% report having experienced a delayed alcohol-induced headache in the past week. 75% of people who have consumed alcohol report having experienced a delayed alcohol-induced headache at least once. Of these, 15% report getting a delayed alcohol-induced headache at least once a month.

Delayed alcohol-induced headaches are often seen as an unpleasant social phenomenon that simply comes with partying. However, it's often overlooked that delayed alcohol-induced headaches increase the risk of reduced work performance, illness, accidents, and even death. The effects of alcohol on the body persist even when no alcohol can be detected in the blood. Affected patients exhibit, among other things, reduced visual spatial perception, memory, and concentration. Their ability to organize and perform tasks is impaired. Corresponding findings have been observed in pilots, drivers, and athletes. The risk of death from cardiovascular events is also elevated. Changes in the electroencephalogram (EEG), auditory processing, dehydration, and balance disorders are observed. The concentrations of antidiuretic hormone (ADH), aldosterone, renin, and cortisol are increased, growth hormone is reduced, and metabolic acidosis develops. The production of pituitary hormones is inhibited.

It is often assumed that delayed alcohol-induced headaches serve as a form of punishment to prevent future alcohol consumption. However, there is no evidence to support this. Nor is there evidence that effective treatment of delayed alcohol-induced headaches promotes further alcohol consumption later on. On the contrary, there is evidence that the occurrence of delayed alcohol-induced headaches makes even higher alcohol consumption more likely. Study data shows that people who experience particularly severe delayed alcohol-induced headache symptoms try to consume even more alcohol to suppress the symptoms.

The exact cause of delayed alcohol-induced headaches remains unclear. Theories include the following mechanisms:

• Delayed alcohol-induced headaches are considered an initial stage of alcohol withdrawal. However, this theory must be countered by the fact that both the hormonal and cardiovascular changes associated with delayed alcohol-induced headaches differ significantly from those of alcohol withdrawal.
• Delayed alcohol-induced headaches are not directly dose-dependent on the amount of alcohol consumed, although higher doses of alcohol may be associated with more severe symptoms. Acetaldehyde, a breakdown product of alcohol, is linked to the development of delayed alcohol-induced headaches.
• Fusel substances in certain alcoholic beverages can increase the frequency and severity of delayed alcohol-induced headaches. They are found particularly in cognac, wine, tequila, and liqueurs. Clear spirits such as rum, vodka, and gin, on the other hand, show a lower incidence of delayed alcohol-induced headaches. This could also explain why clear spirits are more frequently used in cases of chronic alcoholism.
• The symptoms of delayed alcohol-induced headache, such as nausea, headache, and diarrhea, show parallels to a disturbed cytokinin metabolism, as seen, for example, in viral infections. Alcohol leads to an increase in thromboxane. Pain relievers such as tolfenamic acid, a prostaglandin inhibitor, and other NSAID analgesics, taken while consuming alcohol, have a partially preventive effect on the severity of delayed alcohol-induced headache symptoms.
• Hormonal changes have also been associated with the development of delayed alcohol-induced headaches. The severity of delayed alcohol-induced headache symptoms is proportional to the concentration of antidiuretic hormone (ADH). Alcohol inhibits the effect of ADH on the kidneys. This results in an increased urge to urinate that is greater than would be expected from the actual amount of fluid consumed. With increasing dehydration, relative serum levels of ADHA continue to rise. This leads to progressively prolonged excessive fluid loss in patients with delayed alcohol-induced headaches. Accordingly, fluid intake can improve the symptoms of delayed alcohol-induced headaches, although it may not eliminate them completely.
• Alcohol also appears to inhibit glucose availability through an insulin-mediated mechanism. Both acute alcohol intoxication and delayed alcohol-induced headaches result in metabolic acidosis. This inhibits energy uptake in nerve and muscle cells.
• Delayed alcohol-induced headaches cause an increase in heart rate, left ventricular output, and blood pressure. The increased cardiovascular mortality associated with delayed alcohol-induced headaches can be explained by the increased cardiac workload despite normal peripheral resistance.
• The reduction in electrical activity in the electroencephalogram can still be detected 16 hours after blood alcohol levels have normalized. Negative effects on auditory perception, cognition, and psychomotor deficits indicate diffuse cortical inhibition.
• A study has identified a specific hangover gene. Repeated alcohol consumption can lead to the development of alcohol tolerance. This is characterized by an acquired resistance to the physiological, behavioral, and psychological effects of alcohol. Consequently, higher alcohol levels can be consumed, which can promote physical dependence and alcoholism. A specific gene is required for the development of alcohol tolerance.
• Individual differences in sensitivity to and resistance to delayed alcohol-induced headaches are genetically determined.
• A literature review on the occurrence of delayed alcohol-induced headaches consistently showed that 23% of the population is resistant to delayed alcohol-induced headaches. It is likely that this resistance influences drinking behavior and the development of alcohol dependence.
• The severity of delayed alcohol-induced headaches is correlated with an increased risk of alcohol dependence, depression, and other mental health disorders. If delayed alcohol-induced headaches occur only occasionally, those affected should be advised that an alcohol intake of 1.5 g/kg can generally lead to delayed alcohol-induced headaches in all individuals. This amount is reached after approximately 5-6 drinks for an 80 kg man and 3-5 drinks for a 60 kg woman.
• Smoking on days with increased alcohol consumption leads to an increased intensity and likelihood of delayed alcohol-induced headaches.
• Delayed alcohol-induced headaches are more likely to occur in adolescents than in older people.
• Animal experiments have shown that during delayed alcohol-induced headache, mitochondrial dysfunction exists in the cerebellum of mice and can contribute to the persistent effects of alcohol, even though no alcohol can be detected in the blood.
• Both migraines and cluster headaches can be triggered by alcohol. Even small amounts of alcohol can induce these primary headaches. Migraine sufferers consume fewer alcoholic beverages, especially less beer and liqueurs. They are more susceptible to delayed alcohol-induced headaches than non-migraine sufferers. Since even small amounts of alcohol can trigger migraine attacks in migraine sufferers, similar mechanisms are being discussed for the development of migraine attacks and delayed alcohol-induced headaches.
• The precise analysis of the symptoms of delayed alcohol-induced headaches, as well as the factors that cause and modulate them, is incomplete. Standardized measurement instruments for assessing the characteristics of delayed alcohol-induced headaches exist only in rudimentary form. An alcohol dose of 1.5 to 1.75 g/kg body weight, ingested within 4–6 hours, generally results in delayed alcohol-induced headaches. Factors that increase the likelihood of delayed alcohol-induced headaches include inadequate food intake, reduced sleep quality and quantity, increased physical activity, dehydration, and reduced overall physical condition.

Adequate fluid and oxygen intake is the foundation of prevention. Many sufferers only perceive the problem in connection with subjective symptoms such as headaches and a general feeling of illness. Therefore, they should also be made aware of the cognitive, affective, and psychomotor effects of delayed alcohol-induced headaches.

The comparison of the beta-blocker propranolol with placebo in the prevention of delayed alcohol-induced headaches could not demonstrate a significant effect.

In a study, the intake of tolfenamic acid, a prostaglandin inhibitor, showed a preventive effect when taken concurrently with alcohol consumption.

Administering glucose concurrently with alcohol consumption reduced the error rate in reaction time tests 15 hours later by 50%. However, the severity of delayed alcohol-induced headaches was not affected. Another study failed to confirm the effect of glucose or fructose administration on the subjective or objective symptoms of delayed alcohol-induced headaches.

The preventive effect of fructose on delayed alcohol-induced headaches is frequently discussed. A recent animal study demonstrated that honey reduces alcohol-related changes in activity in mice in a dose-dependent manner. Honey also significantly reduced blood alcohol levels in alcohol-intoxicated mice. These findings suggest that honey may indeed counteract the toxic effects of alcohol.

Another study demonstrated a prophylactic effect of vitamin B6. The severity of delayed alcohol-induced headaches was reduced by approximately 50%. During the study, 50% of participants received 1,200 mg of vitamin B6 (400 mg at the start of the celebration, 400 mg three hours later, and 400 mg at the end of the celebration). 50% received a placebo. On a scale of 1 to 10, the participants treated with the active treatment scored 3.2 + 2.8, and the participants treated with the placebo scored 6.8 + 3.8.

The range of treatments and recommendations for delayed alcohol-induced headaches seems endless. Pittler et al. (2005) analyzed the available controlled trials on the treatment of delayed alcohol-induced headaches. The analysis showed that there is no convincing evidence that any conventional or unconventional treatment is effective in preventing or treating delayed alcohol-induced headaches. There is only some evidence that gamma-linolenic acid from borage (borage), tolfenamic acid, fructose, vitamin B6, and a yeast preparation may be effective. However, these studies have not been replicated and were conducted only with small sample sizes.

The best treatment therefore remains the effective prevention of delayed alcohol-induced headaches through moderate alcohol consumption.

Below is a selection of treatment suggestions for delayed alcohol-induced headaches found online. There is no evidence of effectiveness for any of these suggestions.

• Acetylsalicylic acid
• bananas
• Bloody Mary
• Buttermilk
• Calcium
• Cysteine
• dialysis
• Shower
• eggs
• Ice packs
• Fresh air
• fruit juice
• Barley grass
• ginseng
• Glutamate
• Green tea
• Hot bath
• Honey
• Ibuprofen
• Jägermeister
• Coffee
• Cabbage
• Charcoal tablets
• Drink a hair beer
• Milk drinks
• Multivitamins
• olive oil
• Paracetamol
• pizza
• Repair beer
• Raw eggs
• Russian Party
• Sleep
• sport
• Tabasco sauce
• Tomato ketchup
• Vitamin C
• Vitamin B complex
• Water
• Worcestershire sauce
• Lemon juice

Wiese JG, Shlipak MG, Browner WS. The alcohol hangover. Ann Intern Med. 2000, Jun 6;132(11):897-902. Review. PubMed PMID: 10836917.

Pittler MH, Verster JC, Ernst E. Interventions for preventing or treating alcohol hangover: systematic review of randomized controlled trials. BMJ. 2005, Dec 24;331(7531):1515-8. Review. PubMed PMID: 16373736; PubMed Central PMCID:PMC1322250.

Shi P, Chen B, Chen C, Xu J, Shen Z, Miao X, Yao H. Honey reduces blood alcohol concentration but not affects the level of serum MDA and GSH-Px activity in intoxicated male mice models. BMC Complement Altern Med. 2015 Jul 14;15:225. doi: 10.1186/s12906-015-0766-5. PubMed PMID: 26169497; PubMed Central PMCID:PMC4499888.[/fusion_builder_column][/fusion_builder_row][/fusion_builder_container]