Anatomy of a Hangover
Is there a cure for the tragic, albeit self-induced malady?
All About Beer Magazine - Volume 33, Issue 5November 1, 2012
"Never again is what you swore the time before.” These song lyrics from Depeche Mode summarize our feelings about the curse of imbibing: the hangover. The symptoms are unmistakable: headache, body aches, nausea, fatigue and perhaps tremors. It is of little comfort to know that despite its widespread prevalence, medical science has not developed a cure for the hangover. Studies have shown that more than 75 percent of men and women have experienced a hangover at least once in their lives. Another 15 percent experience hangovers monthly. So what works and what doesn’t? My answer might not make you feel better, but at least you will understand why you feel so rotten.What exactly causes veisalgia (the medical term for an alcohol hangover)? Sadly, no one knows. What science does know is that hangover symptoms have a notable impact upon society. “Specifically on lost productivity the last estimate for Canada was [published] in 2006,” tells Dr. Tim Stockwill of the Centre for Addictions Research of British Columbia. Dr. Stockwell is referring to a report written by Dr. Jürgen Rehm and associates for the Canadian Centre for Substance Abuse (www.ccsa.ca). In this 2006 report, $23 million dollars and 227,000 days in were lost to reduced activity due to short-term disability from alcohol abuse in the year 2002. In the United States this figure is closer to $148 billion. The toll is especially hard on college students. One study, published in the June 2000 edition of the Annals of Internal Medicine, found that 29 percent of students reported having to miss classes to recover from a hangover. Despite the widespread occurrence of this tragic, albeit self-induced, malady there has been little research done to find a cure. The Cause, Mostly Theoretical There are many theories about what causes a hangover. The most plausible theory is that excessive alcohol consumption causes dehydration and electrolyte imbalances. We all know that beer can act as a diuretic (something that makes you urinate more). “Excessive alcohol consumption can interfere with pituitary secretion of vasopressin”, explains Dr. Dan Martinusen, Clinical Pharmacist specializing in kidney disease for Vancouver Island Health Authority. Vasopressin, or antidiuretic hormone, normally helps the kidneys reabsorb water. With less of this hormone around, your kidneys are unable to conserve water causing you to make more trips to the washroom. This is why there are so many port-a-potties at beer festivals. “The resulting diuresis (increased urine production) may lead to rapid dehydration and subsequent shrinking of the dura mater surrounding the brain.” Dura mater is a connective tissue lining that surrounds the brain and spinal cord connecting it to your bones. Dr. Martinusen further explains that one possible cause of headaches is contraction of this dura mater. He continues, “this is certainly a plausible theory for headache symptoms during an alcohol hangover.” Electrolyte imbalances often follow excessive urine output. Sodium and potassium are carried away in the urine. Symptoms of mild dehydration include thirst, dry mouth, dizziness, nausea/vomiting and muscle cramping. Dehydration may be further worsened if vomiting, diarrhea or excessive sweating is present. To understand the next hangover theory, perhaps we should learn how ethanol is removed from the body. In a multi-step process, your body converts ethanol to carbon dioxide and water. The first step in this process is when an enzyme called alcohol dehydrogenase converts the ethanol to acetaldehyde. Next, your metabolic best friend, acetaldehyde dehydrogenase, converts this toxic acetaldehyde to harmless acetic acid. This process is not prefect, nor is it quick. These enzymes work at a constant rate, so removal of these toxic materials can take some time. A build up of acetaldehyde can cause symptoms of flushing, nausea and headaches. The hangover is often blamed on the impurities within alcoholic beverages. These impurities are collectively called congeners. There is a bit of truth to this theory. Research has shown that “cleaner” spirits (gin or vodka) tend to produce fewer hangovers than “congener rich” spirits (whiskey, cognac or red wine). This theory was confirmed by researchers at the Center for Alcohol and Addiction Studies, Brown University, Providence, RI. In a study published in the March 2010 edition of journal Alcoholism:Clinical and Experimental Research, young drinkers either received bourbon or vodka to the point of intoxication. On the morning following bourbon consumption, subjects felt their hangover was more severe compared to the mornings after they drank vodka. Craft beer lovers crave congeners; these impurities are responsible for flavor, smell and appearance. In smaller amounts, congeners give beer and other alcoholics beverages their characteristic flavors. Too much and you will have a difficult time clearing them from your body. The problem may not the congeners themselves, but how your body processes them. The enzymes that breakdown ethanol, also breakdown other forms of alcohol in your pint glass. Perhaps the most notorious congener is methanol, which is more of a concern for distilled spirits. Alcohol dehydrogenase converts methanol to formaldehyde. The symptoms of methanol ingestion mimic hangover symptoms perfectly. Heaven only knows what these enzymes produce from the fusel alcohols, esters and phenolics present in beer. Not all morning-after woes can be blamed on congeners; pure ethanol can still cause a hangover. Low blood sugar is another theorized cause of hangover symptoms. It is true that symptoms of low blood sugar mimic hangover complaints: hunger, weakness, sweating, trembling and confusion. In reality, low blood sugar from alcohol consumption only occurs under certain circumstances: chronic alcoholism, low carbohydrate diets or not eating enough. Alcohol can deplete glycogen (energy) stores in the liver, but this generally takes several days to occur. People with diabetes are more sensitive to alcohol-induced changes in blood sugar. Lack of sleep is also thought to contribute to hangover symptoms. While alcohol can act as a mild sedative, quality of sleep is affected. Time spent in the restful rapid eye movement (REM) sleep is reduced with alcohol intoxication. Alcohol relaxes throat muscles, which may cause snoring and possibly sleep apnea. Imbibing can also reduce the body’s production of melatonin, which is required for a restful sleep. While it is true that beer does contain melatonin, its presence is minor and not thought to be significant enough to help with sleeping. Pair this with any other sleep disturbances and you have one tired beer geek. Let’s not forget that alcohol is a diuretic; frequent nighttime trips to the bathroom won’t help matters. Are symptoms of sleep deprivation similar to a hangover: muscle aches, depression, headaches, nausea, fatigue, memory lapses and irritability. Sounds right to me. “There is extensive literature on the effects of alcohol on sleep,” explains Dr. Jonathan Howland Professor of Community Health Services at Boston University. “Alcohol can affect sleep architecture and breathing (apnea) and both these effects can disturb sleep. He points to research that appeared in the May 2011 issue of the journal Alcoholism: Clinical Experimental Research. In this study researchers gave healthy adults sufficient bourbon or vodka to reach a breath blood alcohol concentration of 0.11g percent. After being tucked in for the night, researchers followed the imbibers sleep patterns. What they found was that subjects fell asleep faster, but their sleep was not as restful. They experienced less REM sleep, greater wakefulness and more slow wave sleep. He further explains, “The connection we investigated had more to do with heavy drinking effects on next-day performance rather than on hangover, but fatigue is associated with hangover.” Another fascinating theory of the hangover is that it could be acute alcohol withdrawal. This is based on the fact that these two conditions share similar symptoms. They both can cause nausea, confusion, headaches, sweating and anxiety. Another observation to support this theory is that ingestion of alcohol can relieve symptoms for both conditions. This is the “hair of the dog” hangover remedy. However, there are arguments against this theory. In the hangover state there is decreased brain activity, while there is increased activity and excitability during alcohol withdrawal. To make things more complicated, in certain studies alcoholics have not experienced hangover symptoms. Yet these same alcoholics have experienced withdrawal symptoms. The Cure? Please Let There Be A Cure. Now to get to the important part, how does one cure or prevent a hangover? A quick search of Google produced over 1 million hits for hangover cures. What works and what does not? Are there any scientific studies that tried to find a cure for this morning after syndrome? The answer might upset you, but let’s look at the most popular cures for the hangover. Running or vigorous exercise is a supposed to be a sure-fire prevention and cure for the hangover. The theory is that aerobic activity will increase metabolism and help your body burn off alcohol. This does make a bit of sense and it could also help to reduce driving while under the influence. However, there is no proof that this works and it could be dangerous. Vigorous activity may lead to further dehydration and actually make symptoms worse. It is also not a good idea to exercise while in an impaired mental state; it might lead to injuries. Perhaps you should drink plenty of sport drinks before going to bed or in the morning. This idea also makes sense. It helps with two causes of hangovers: dehydration and electrolyte loss. The same argument could be made for drinking coconut water. There are a few drawbacks to this course of action. Sport drinks contain a lot of sugar and could lead to weight gain and dental cavities. Fluid consumption before bed might lead to many nighttime bathroom trips, which may interfere with getting adequate sleep. Maybe a small glass of water before bed might be a better idea. Don’t forget to have a big glass of water or other fluid beside your bed for the morning. Perhaps a better idea would be to drink water during your night on the town. How about taking an over the counter painkiller before bed such as ibuprofen or acetaminophen? This sounds good in theory, but it really is a bad idea. The combination of alcohol and acetaminophen could lead to liver damage. Alcohol metabolism interferes with the livers ability to remove acetaminophen from the body. This build up can be toxic to your liver. Ibuprofen and other anti-inflammatory drugs should not be combined with alcohol either. Both alcohol and anti-inflammatory drugs are irritants to your stomach. This might lead to further stomach upset or worse: a stomach ulcer. What about the “hair of the dog that bit you” remedy? Earnest Hemingway was rumored to drink beer and tomato juice to cure his hangovers. There is a bit of theory behind this idea. Ingestion of ethanol can reduce the breakdown of congeners into further toxic by-products. Alcohol can act as a painkiller and will help withdrawal symptoms. Shawn Soole, Executive BarKeep - Clive’s Classic Lounge, Tales of the Cocktail “World’s Best Hotel” nominee gives his remedy for a hangover: “My favorite hangover cure is a Fernet Branca, a lager and a good spicy gin caesar and not in that order. The lager winds you down, the Fernet winds you up and the spicy caesar gets you ready for the day.” Strong black coffee has been a hangover cure that has survived the test of time. The high caffeine content will help to reduce the drowsiness associated with a hangover, but that is about it. It might make things worse. Coffee and caffeine can be stomach irritants and potentially act as a diuretic. This further fluid loss will only compound the problem. The notion that eating a fatty breakfast with eggs is one miracle cure that just might work. Eggs are an excellent source of the amino acid L-cysteine. This same amino acid can bind to acetaldehyde and block its toxic effects. Most of this theory comes from research done on rats in the 1970’s. Rats were given a lethal dose of acetaldehyde and either L-cysteine, thiamine (vitamin B1) or both. Researchers found that those rats that survived were given both L-cysteine and thiamine. There are two reasons for this lucky outcome. Both L-cysteine and thiamine bind to acetaldehyde to form a stable and non-toxic product. Acetaldehyde is also a very toxic chemical and causes oxidative damage to various organs. L-cysteine helps replenish glutathione; your bodies primary anti-oxidant defense. Sadly, there is no proof that L-cysteine will help with hangovers in people. You might have heard about N-acetyl cysteine (NAC). NAC is similar to L-cysteine but it is a little better utilized by the human body. So will eating a fatty egg breakfast help with a hangover? Probably not, but it will help to replace lost electrolytes, carbohydrates and fluids. It also might help to settle your stomach. Or maybe you should just stick to dry toast and lots of water. Certainly taking vitamins before bed will help with a hangover? Don’t the B-vitamins help with alcohol metabolism? Hawkeye Pierce from M*A*S*H self administered thiamine (vitamin B-1) injections to help him sober up. Sorry, not going to help. It is true that chronic alcohol intake is associated with lower amounts of thiamine in the body. Chronic alcohol ingestion can deplete the body of this important vitamin. That is why alcoholics tend to have thiamine deficiency diseases: nerve damage, heart disease, confusion and problems with muscle coordination. When you give extra thiamine, these alcohol induced health problems tend to get better. Thiamine is not directly involved in the removal of alcohol from your body. Actually, niacin (vitamin B3) is more activity involved in the removal of alcohol from the body. Again taking extra niacin will not help with a hangover. There was one old study which demonstrated that high doses of vitamin B6 can help improve hangover symptoms by 50 percent. Sadly, it was a semi-synthetic form of this vitamin that is not available at the health food store. The doses used were also very high, about 1200mg a day. Oddly, the researchers did not know why or how this vitamin worked. What is the real hangover treatment proven by medical science? Sadly there is none. I’m sorry if your hopes for a cure were shattered. The oldest remedies still work best: try to sleep it off, stay hydrated and eat well. Perhaps prevention is the best option. For each pint you drink, follow that with a chaser of water. Pace yourself; I know it tastes good but think about the possible consequences in the morning. Don’t forget to eat something. The presence of food in the stomach, especially high fat foods, will slow the absorption of alcohol into the body. On the morning of the hangover, try to eat bland and simple foods to help settle your stomach. For me, an apple a day keeps the hangover away. By all means take a good quality multivitamin. It might not help with a hangover, but there are many other benefits for your body. Treatment of specific hangover symptoms might be helpful. Consider taking dimenhydrinate (Gravol or Dramamine) for symptoms of nausea and vomiting. Placing an icepack on the head, or the back of the neck, might be a better idea for headaches than over the counter painkillers. Or just drink a big glass of water and go back to bed. Maybe these horrible feelings will be a deterrent from future overindulgence. Probably not; painful memories fade fast.
Ian Lloyd is a pharmacist and freelance writer.