Drug and Alcohol Dependence, ll(1983) 249-269 Elsevier Scientific Publishers Ireland Ltd.
SIGNS AND SYMPTOMS OF HANGOVER: PREVALENCE AND RELATIONSHIP TO ALCOHOL USE IN A GENERAL ADULT POPULATION
CEDRIC M. SMITH and GRACE M. BARNES* Research Institute on Alcoholism, New York State Division of Alcoholism and Alcohol Abuse, 1021 Main St., Buffalo, NY J4203 and Department of Pharmacology and Therapeutics, State University of New York at Buffalo, Buffalo, New York (U.S.A.) (Received October
SUMMARY The post-intoxication state, commonly called hangover, has been known since antiquity; yet there has been little systematic research examining the signs and symptoms of hangover among the general population. The frequency and the various symptoms of hangovers, as well as the relationships between hangovers and alcohol consumption, were analyzed using a sample of 1041 adults 18 years and older living in Western New York State. Hangovers were experienced in the previous year by only about 50% of the population of heavier drinkers; the frequency was even less among those with lower alcohol consumption. Factor analysis of the various symptoms revealed significant clusters. The findings suggest that the aversive aspects of alcohol consumption, including the hangover syndrome, may deter excessive consumption; certain individuals in whom aversive reactions as hangover do not occur maybe at high risk for excessive alcohol use.
words: Hangover - Alcohol consumption - Alcoholism survey -Post-intoxication syndrome - Deterrents
The unpleasant state that follows a period of intoxication by an alcoholic beverage, the post-intoxication state 111, is commonly referred to by the rather general term, hangover, or by a variety of more colloquial, descriptive terms such as the crapula, Katzenjammer or Kater (German: wailing of cats or tomcat), stonato (Italian: out of tune), gueulc de bois (French: woody mouth), att ha kopparslagare (Swedish: to have ‘coppersmiths’ or ‘copper*To whom reprint requests should be sent. 0376-8716/83/$03.00 @ 1983 Elsevier Scientific Publishers Printed and Published in Ireland
hammering’) or honti i haret (Norwegian: pain in the roots of the hair). The hangover and effects of chronic alcohol use have been known since antiquity; they are described in detail, for example in the Ayurveda, the ancient system of medicine of India [21.* As Chapman  noted in the introduction to the first truly definitive, experimental study of hangover, the unpleasant after-effect of drinking alcoholic beverages has received surprisingly little formal study’. Although it is a common experience, even for a fairly large percentage of moderate drinkers, the nature of the hangover syndrome(s) and its character, magnitude and frequency in relation to the patterns and amounts of drinking and to beverage type have not been systematically examined. The studies of Chapman and a series of investigations by the Finish group of Ylikahri and coworkers [EL121have demonstrated that this syndrome can be defined and measured with a high degree of accuracy by both subjective ratings and physical signs. The syndrome reportedly does vary in character among individuals and occasions; the most frequent symptoms usually reported are thirst and a sense of fatigue and malaise; a pulsatile or steady headache is said to be common, but perhaps may be evidence of a somewhat more severe sickness [4,131. In addition to headache, among the common symptoms is nausea, which sometimes is accompanied by vomiting. In part, the nausea and vomiting are associated with nystagmus which may derive, not from the neuronal effects of alcohol, but from its osmotic disturbance in the labyrinth . Other signs and symptoms include tremor, waves of hot and cold feelings, perspiration and weakness. Psychological symptoms and feeling states include depression, guilt, remorse, anxiety and extreme sensitivity. Most investigations have emphasized the individual variability in susceptibility to hangover and an individual susceptibility to a specific syndrome. Unfortunately, the listing method of Ylikahri and coworkers (e.g. Ref. lo), although it uses a precise scale system that had good experimental utility and validity, does not permit the tabulation and delineation of specific different types of hangover syndromes. Thus, the definition of hangover is far from unambiguous, since if one inquires from a number of individuals, rather striking differences are apparent in their descriptions of what constitutes a hangover. The intensity of the hangover syndrome is clearly related to the total amount of alcoholic beverage consumed [4,51. Taking,small amounts of alcohol results in unpleasant effects or a dull headache in only a very few people. Hangover intensity and the frequency of its occurrence increases *Unfortunately, the same word, hangover, is also used to denote the persistence of the effects into the morning after of a hypnotic drug taken to facilitate sleep the night before. Adding further confusion is Karpman’s book, Hangover 131, in which Bangover’ is used to describe not only the ‘morning after but a variety of syndromes associated with alcohol abuse, alcoholism and withdrawal.
with the amount of alcohol consumed. An average borderline amount above which hangover risk increases seems to be of the order of 5 or more drinks ingested over a l-2-h time span. For example, in an unpublished pilot survey of 30 medical students, we found that 16% reported hangovers of some sort after 5-7 drinks. Approximately 50% of those with EL10 drinks or more reported hangover; most of these had headache and nausea; some had vomiting and some reported anxiety. In these retrospective surveys and studies of experimental drinking, almost half of the individuals did not experience a hangover. Whether they would have, had the amount of alcohol consumed been increased, remains a moot question. Clearly, some people are less susceptible to whatever processes are involved in the occurrence of hangovers. One of the prime reasons for an interest in hangover is the question of the degree to which it modifies or regulates the drinking by the individual, i.e., regulation of the amount, type of beverage, drinking pattern and setting. It would seem plausible that those individuals who had severe hangovers from the first episodes of drinking would be less likely to consume that beverage, in that amount, on future occasions. During an evening in which alcoholic beverages are ingested, a headache or stomach upset may occur late in the evening; unpleasant feelings sometimes progress to become more severe, with the peak intensity of discomfort sometime the next morning. These discomforts may cause individuals experiencing them to restrain their alcohol consumption or the duration of their drinking to a level that is not associated with the more unpleasant aspects. According to this line of reasoning, one might expect to find a positive correlation between the frequency and intensity of hangovers associated with a given level of drinking or an eventual reduction of consumption. Or put differently, at any point in time, if hangovers were a prime controller of drinking, all of those drinking would be expected to exhibit an equivalent prevalence of hangover. Anecdotally at least, there is some confirmation of this in the sense that many heavy drinkers who appear in alcohol treatment programs do not have, and have not had, severe hangovers. A recent test of this idea in alcoholic patients undergoing detoxification revealed that in spite of very large intakes, half had no hangovers in the past; moreover, 23% convincingly reported that they had never experienced a hangover 1151. In fact what many described as a hangover’ was, more often than not, a binge of many days of heavy drinking and intoxication. Many of these individuals were capable of ingesting large amounts of alcohol over hours and days without the appearance of any post-intoxication hangover sickness. On the other hand, it seems likely that the hangover may also play a role in sustaining excessive drinking by stimulating drinking designed to treat the hangover, that is, the use of ‘the hair of the dog’ to alleviate the hangover. Thus, it is possible that some excessive drinking may excite further, repeated drinking. Post-intoxication states may constitute a central manifestation of the
biological dependence syndrome and represent, at least in some of its forms, the initial signs of an abstinence, or withdrawal, syndrome [10,16-191. It is important to differentiate, where possible, between the post-intoxication state or hangover and the appearance of a withdrawal syndrome. Just as the hangover syndromes appear to form clusters, depending on the individual, the withdrawal symptoms have been found to cluster around three factors 1201. The first factor included nausea, tinnitus, visual disturbances, pruritus, paresthesias, muscle pain and hallucinations. The second factor included tremor, sweating, depression and anxiety, and the third, disturbances of consciousness, guilt, contact with reality and nystagmus. It seems obvious that the last of these factors was directly related to either alcohol-induced sedation or nervous system impairment, whereas factor two included characteristic signs of early and/or mild withdrawal, and factor one included a mixture of nervous system hyperexcitability and disturbed function. However attractive the hypothesis that the hangover constitutes an acute abstinence syndrome, the description of the abstinence syndrome after chronic heavy drinking centers on tremor, anxiety, motor and autonomic hyperexcitability. Headache or thirst are rare. Common to both the hangover and the withdrawal syndrome are nausea, vomiting and gastrointestinal upset. It was interesting that this study of Mendelson and Mello failed to find any evidence that the intensity and pattern of the withdrawal syndromes were directly related to the volume of alcohol regularly consumed. They concluded, on the basis of their questionnaires, that the withdrawal signs and symptoms were primarily related to the number of years of heavy drinking. However, a recent study did find, albeit in the presence of appreciable variability, a statistically significant correlation between the amount of beverage intake over the previous week and the severity of the withdrawal sickness 1151. In spite of the problem in differentiating withdrawal and hangover, one symptom clearly distinguishes the two phenomena: headache is an extremely infrequent symptom in withdrawal (Pristach and Smith, clinical observations). The fact that not only is amount, but type of beverage, important in hangover has been long known and perhaps better studied than any other facet. This aspect is reviewed in some length in the discussion section. Studies on the roles of hangovers in the production of chronic excessive alcohol intake have received only sporadic attention. An explicit study of this was carried out in Europe by Zav’yalov 1211. Of 103 people queried, 98 stated that although they found morning drinking disgusting, they found that drinking, in response to their friends’ suggestion, was helpful in alleviating the symptoms of hangover. In this study it appeared that the character of the hangover experience changed over the years and many never experienced any nausea or vomiting as part of the hangover. This sequential change over years of drinking was also mentioned by Tuominen 1221 in which during the early years the hangover symptoms
included general indisposition, headache, vomiting, whereas in later years tension, irritability, sleeplessness, depression were the more predominant symptoms. Late in a chronic drinking career, drinking became targeted on calming, as Jack London put it: ‘the maggots of the mind’ . (See also the extensive essay by Lolli ). Although there is little proof, our working hypothesis remains that drinkers who do not suffer some hangover signs and symptoms are appreciably more at risk of heavy drinking than are those who are especially sensitive to hangover. The latter presumably will learn to keep their drinking, for the most part, below the threshold for the hangover and/or limit their heavy drinking episodes to relatively infrequent occasions. METHODS
A stratified random sample (N = 1041) of adults aged 18 years and older was selected from the two-county Buffalo Standard Metropolitan Statistical Area in Western New York State. Using a computer-generated respondent selection key, an eligible adult was randomly selected from each household for a personal interview. Details of the sampling procedures have been published elsewhere [25,26]. Questions on alcohol use followed the slightly revised version  of the methodology used in the national survey of American drinking practices 1281.These standardized quantity-frequency-variability questions were used in the present survey to permit comparisons between data on current drinking practices in New York State and those reported in the nation as a whole 1261. More specifically, the participants in the study were asked to indicate how often they drank wine; and they were given a card listing ten categories, ranging from three or more times a day to never. They were then asked to report how often they drank five or more glasses of wine, and they were given five categories to choose from, ranging from nearly every time to never. In the same way, they were then asked how often they drank three or four glasses of wine and how often they drank one or two glasses of wine. This set of four basic questions was repeated again for beer and for liquor (i.e. whiskey, vodka, mixed drinks, etc.). In addition to the questions on alcohol consumption, the interviewing schedule included questions on the frequency of having a hangover in the past year and for former drinkers, the frequency of hangovers in an average year before they stopped drinking. Respondents were also asked to think of the last time they had had a hangover and to respond as to whether or not they had various signs and symptoms often associated with hangovers. This list included having a headache, being sick to the stomach, having hands shaking, feeling nervous or anxious, feeling depressed, having hot flashes or cold chills and vomiting. The alcohol portion of the questionnaire also included questions on the
frequency of intoxication, of driving after ‘having too much to drink,’ and of being criticized by one’s spouse or family member because of drinking and the perceived effects of alcohol on the respondent’s health. The information generated by the responses to the drinking questions have been used to derive the Absolute Alcohol (AA) Index. As developed by Jessor et al. 1271 the AA Index for a respondent is the summed product of the frequency score for each beverage (converted to a per day unit) and the weighted average quantity of absolute alcohol intake for each beverage. Thus, the AA Index represents the average ounces of absolute alcohol consumed per day. More specifically, a score of l.O+ ounces of absolute alcohol per day (i.e. an average of 2+ drinks per day) has been used in national studies  to denote heavier drinking.*
Prevalence of hangovers and hangover symptoms The vast majority (86%) of Western New York adults report drinking at least occasionally during the preceding year. Slightly more males (89%) than females (84%) are current drinkers and approximately three times as many males (33%) as females (9%) are classified as heavier drinkers 1261. Of the current adult drinkers, approximately one-third (35%) report having at least one hangover during the past year; 27% of the female drinkers and 42% of the male drinkers report one or more instances of hangovers in the preceding year (Table I). Eleven per cent (11%) of the male drinkers describe hangovers ranging from at least six times in the year to as often as once a week. Among adults in the general population who have ever had a hangover, the vast majority include having a headache (79%) as part of the hangover (Table II). For over half of the people (57%), hangovers are accompanied by nausea and a third (34%) report vomiting. Smaller, yet significant, proportions of the population report depression (20%), nervousness (18%), hands shaking (12%) and hot or cold flashes (12%) as symptoms associated with hangovers.
*The denotation of heavier drinking as given in this drinking classification scheme cannot be equated with ‘problem drinking’ or a diagnosis of ‘alcoholism’. However, findings do indicate that heavier drinkers are at a greater risk for various alcohol-related problems (such as marital problems or instances of driving while intoxicated) than are more moderate or infrequent drinkers. Because this scheme combines various drinking behaviors, some of the precision of an individual’s drinking history are confounded. For example, since the AA Index is an average daily consumption estimate, it masks certain types of drinking behaviors, such as binge drinking. Nevertheless, for examining the relationships of various factors to drinking, this definition of heavier drinking is very useful for aggregating those persons at the upper end of the drinking spectrum in a general adult population.
255 TABLE I FREQUENCY OF HANGOVERS AMONG MALE AND FEMALE CURRENT DRINKERS IN THE ADULT FOF’ULATION OF ERIE AND NIAGARA COUNTIES No. hangovers in the past year
Males (N = 426)
Females (Iv = 470)
Roth eexea (N = 896)
None 1 2 or 3 4 or 5 6-10 13lmonth l/week or more often No responee
59% 14% 13% 4% 3% 5% 2% 1%
73% 12% 8% 3% 2% 1% -8
66% 13% 11% 4% 2% 3% 1% 1%
“Less than 0.5%.
This same rank ordering of symptoms associated with hangovers applies for both males and females (Table III). The magnitude of the prevalence of some symptoms varies somewhat according to sex; i.e. there is a tendency for more females than males to report headaches (83% vs. 75%), nausea (62% vs. 53%) and vomiting (38% vs. 31%). The differences among males and females for the remaining symptoms (i.e. nervousness, depression, hands shaking and hot/cold flashes) are not large. Examining the sex-specific mean ages of persons reporting that they either have or have not had the various symptoms associated with hangovers reveals only two groups with statistically significant differences. Women who report having hands shaking and hot/cold flashes tend to be younger (30.5 years alld 33.5 years, respectively) than those denying these two specific symptoms (39.2 years and 39.4 years, respectively).
TABLE II FREQUENCY OF SYMPTOMS ASSOCIATED WITH HANGOVERS AMONG ADULTS IN ERIE AND NIAGARA COUNTIES WHO REPORTED EVER HAVING HAD A HANGOVER Question was stated: Think of the last time you had a hangover. Did you have.
Headache (N = 630)
Nausea (N = 639)
HaMlE shaking (N = 613)
Nervousness (N = 617)
Depreesion (N = 627)
Hot/cold flashes (N = 625)
Vomiting (N = 639)
‘Indicates that the person reported having the particular symptom in conjunction with a hangover. bIndicatee that the person reported not having the particular symptom in conjunction with a hangover.
Female (N=296) 18% 02%
Male (N=329) 11% 99%
Female (N=291) 17% 33%
IN ERIE AND NIAGARA
‘Indicatea that the pereon reported having the particular symptom in conjunction with a hangover. bIndicates that the person reported not having the particular symptom in conjunction with a hangover.
FREQUENCY OF SYMPTOMS ASSOCIATED WITH HANGOVERS WHO REPORTED EVER HAVING HAD A HANGOVER
and average ethanol intake
The number of hangovers is greater for those who report heavier alcohol intake than for others in the population. Abstainers, for obvious reasons, report almost no hangovers, whereas heavier drinkers, male or female, experience the most; 24% and 35%, respectively, of the heaviest drinking category report having had 4 or more hangovers in the past year (Table IV). However, nearly 40% of the women and almost 50% of the men in this heaviest drinking group had no hangovers in the past year.
The rank-ordering in the frequency of the various hangover symptoms is nearly the same for both light/moderate and heavier drinkers (Table V). More specifically, both light/moderate and heavier drinkers report headaches associated with hangovers with the greatest frequencies (80% and 76%, respectively). Heavier drinkers report nausea (43%) and vomiting (25%) less frequently than do light/moderate drinkers, i.e. 61% of the light/moderate drinkers report nausea and 37% have vomiting associated with hangovers. However, nausea and vomiting hold the second and third frequency ranking for heavier drinkers as they do for light/moderate drinkers. Heavier drinkers tend to be more likely than light/moderate drinkers to have hands shaking (18% vs. 10%) and nervousness (21% vs. 15%) in association with hangovers. The male-specific data show these differences even more distinctly than do the total population data. Heavier drinking males, in comparison with light/moderate drinking males, report less headaches (70% vs. 79%) less nausea (45% vs. 58%) and less vomiting (23% vs. 34%) associated with hangovers. On the other hand, male heavier drinkers tend to have more nervousness (23% vs. 12%), hands shaking (17% vs. lo%), hot and cold flashes (10% vs. 7%) and depression (23% vs. 21%) than do males who are more moderate drinkers. (The data for females are less conclusive since the number of females who are heavier drinkers and report these various hangover symptoms is relatively small, i.e., approx. 35). Looking at the relationship of alcohol consumption and hangover symptoms from another perspective, the average ethanol intake was compared for those persons reporting that they have had a particular symptom and those who have had a hangover, but not that particular symptom (Table VI). There were no significant differences in the mean ethanol scores for males who report headaches in conjunction with hangover and those who have hangovers but do not have headaches. Similarly, females who do have headache symptoms and those who do not, do not differ significantly with regard to their average daily ethanol intake. This finding of no statistically significant differences in average alcohol consumption also applies with regard to the symptoms of nausea, vomiting and depression. However, both males and females who report hands shaking and hot/cold flashes have significantly higher mean average ethanol intake scores.
7% 20% 35%
12% 15% 24% 21; 18% 21%
80% 79% 82%
76% 70% 94%
Light/Moderate male female
Heavier male female
37% 34% 39% 25% 23% 34%
61% 58% 62%
48% 45% 59%
“Average ethanol intake 20 and (1 oz./day. bAverage ethanol intake 21 oz./day.
8960 14% 23%
(N= 265) 67% 13% 11% 9%
21% 23% 13%
15% 12% 18%
21% 23% 14%
19% 21% 17%
18% 17% 22%
10% 10% 9%
10% 7% 13% 12% 10% 20%
(N= 96) 99% 1%
(IV= 54) 98% 2% -
(IV= 409) 76% 13% 8% 4%
IN ERIE AND NIAGARA
>O.O and cl.0
OF LIGHT TO MODERATE”
Type of drinker
Hangovers in the past year None 1 2-3 4 or more
>l.O and ~2.0
IN THE PAST YEAR FOR ADULTS AND SEX
FREQUENCY OF HANGOVERS AVERAGE ETHANOL INTAKE
Female 1.11 1.41
Female 2.53 1.10 *
Male 0.69 0.47
Male 0.75 0.46
2.68 1.21 *
at the P < 0.05 level.
0.79 0.46 *
IN ER.IE AND NIAGARA
BIndicates that the person reported having the particular symptom in conjunction with a hangover. %uIicates that the person reported not having the particular symptom in conjunction with a hangover.
*T-test indicates that the difference between the Yes’ and ‘No’ groups is statistically
MEAN AVERAGE ETHANOL INTAKE (IN OUNCES PER DAY) FOR MALES REPORTED VARIOUS SYMPTOMS ASSOCIATED WITH HANGOVERS
2.07 1.26 *
1.09 0.45 *
Given the seven individual hangover symptoms, a factor analysis was performed to determine whether or not there may be an underlying pattern to these separate variables such that they might be reduced to a few components. The resulting factor matrix (Table VII) indicates a reasonably good fit of the individual symptoms into three distinct factors. The first factor consists of hands shaking, nervousness, depression and hot/cold flashes. The second factor is comprised of the nausea and vomiting symptoms; and headache alone makes up the third factor. (The respondents’ scores associated with each item [Yes = 1 or No = 21 in a particular factor have been totaled to derive a score for each factor for subsequent analysis. For example, for a person who reports having all seven symptoms, Factor 1 would equal 4; Factor 2 would be 2; and Factor 3 would equal to 1.) In determining how these symptom factors are distributed throughout the population, the data reveal that approximately a quarter (24%) of the males and a fifth (20%) of the females reporting hangovers have symptoms only from Factor 3 (headaches). An additional 22% of the males and 32% of the females have Factor 3 and Factor 2 (i.e. headaches as well as nausea and/or vomiting) symptoms; and somewhat smaller proportions of males (13%) and females (9%) report symptoms only from Factor 2. While small percentages of males (5%) and females (3%) have only Factor 1 symptoms (i.e. hands shaking and/or nervousness and/or depression and/or hot/cold flashes), Factor 1 symptoms alone or in combination with the other two factors are reported by 41% of the males and a similar 40% of the females who have ever had a hangover. It might be expected that different drinker types might have different scores on the hangover-symptom factors. Such is not the case for females (Table VIII); the scores for light/moderate and heavier female drinkers are TABLE FACTOR
Principal component factoring with orthogonal rotation (Quartimax) was used for this analysis to transform the variables into components that are orthogonal funcorrelated) to each other. No specific assumptions regarding the underlying structure of the variables are required for principal component factor analysis. Factor 1 Headache Sick to stomach/nausea Hand shaking Nervous or anxious Depressed Hot flashes/cold chills Vomiting “Items used as components
0.00 0.09 0.74” 0.75” 0.48” 0.58” 0.06 of the factor.
Factor 2 0.02 0.85” 0.01 0.03 -0.05 0.13 0.86”
Factor 3 0.93” -0.05 -0.06 0.10 0.33 -0.18 0.06
0.68 (N = 0.91 (N = 0.94 (N = 2.50 (N =
Heavier drinkers (average absolute alcohol 2 1 oz./day)
+ depression + hot/cold flashes
0.56 (N = 1.01 (N = 0.82 (N = 2.38 (N =
0.72: (N = 0.68’ (N = 0.70 (N = 2.06 (N =
0.48 (N = 0.92 (N = 0.79 (N = 2.16 (N =
Light/moderate drinkers (average absolute alcohol 10 and
P < 0.05
AND FOR HEAVIER
Heavier drinkers (average absolute alcohol 2 1 oz./day)
Light/moderate drinkers (average absolute alcohol 10 and
between the two drinking
“Factor 1, hands shaking + nervousness + depression + hot/cold flashes. bFactor 2, nausea + vomiting. cFactor 3, headache. dTotal symptoms, headache + nausea + vomiting + hands shaking + nervousness
not statistically different on any of the three factors nor on the total hangover symptom score. The findings for males are somewhat different. Heavier drinking men score significantly higher on Factor 1 than do more moderate male drinkers. On the other hand, heavier drinking males have significantly lower Factor 2 scores (nausea and vomiting) than do males who are classified in the light/moderate drinking category. Interestingly, the Factor 3 scores for headache are not significantly different among the two male drinking groups and the total symptom scores do not differ across the two drinking classifications. Beverage preference
The following beverage-specific data based on the present general population study are illustrative of the type of analyses that are needed to develop a better understanding of the notion that different types of alcoholic beverages may be differentially associated with hangover effects. Despite the fact that this survey involved a relatively large sample of adults, the necessity to control for a number of variables with regard to alcohol consumption, beverage type, and occurrence of hangover, results in rather small numbers in many cells; thus, the findings in this section are not conclusive and interpretations must be made with caution. Nonetheless, the results do provide a foundation for further study. The clear majority of male heavier drinkers in Western New York State (73%) ‘prefer’* beer; 19% of the male heavier drinkers ‘prefer’ liquor whereas only 9% ‘prefer’ wine. By comparison with the males, a smaller but sizeable proportion of female heavier drinkers ‘prefer’ beer (44%). Equal percentages of women heavier drinkers ‘prefer’ wine (28%) and liquor (28%). When controlling for beverage preference and alcohol consumption (e.g. heavier drinking) in the examination of the prevalence of hangovers and their associated symptoms, the numbers of heavier drinkers who prefer beverages other than beer are small. Thus, from the available data, no meaningful differences in frequency of hangovers or hangover symptoms could be discerned which were attributable to preferences for one of the three major alcoholic beverage types, while controlling at the same time for the amount of alcohol consumed. Studies to detect differences will need to include procedures for oversampling persons who prefer the different types of beverages. DISCUSSION
The results of this large scale general population survey and of more targeted inquiry from patients hospitalized for acute detoxification reveal
*Beverage preference was determined by the beverage portion of respondent’s average daily ethanol intake.
for the greatest
that in spite of the fact that hangover has been well known as a phenomenon, it is no way a universal ,experience, even among individuals who drink large quantities of alcohol. The factors that have been demonstrated to be related to the appearance or absence of a post-intoxication hangover syndrome include, besides individual susceptibility, the total amount consumed [4,5], the type of beverage, and a complex of psycho-social factors, including the amount of guilt that is associated with drinking, as demonstrated recently by Gunn 1303 and Harburg et al. 1311. We have been impressed not only by the fact that these factors are important in the production of hangover, but that there is both a remarkable individual susceptibility and that the syndrome itself, although labelled a hangover by the individual, may be quite different among various individuals. On the one hand it seems quite clear that up to 50% of the individuals might be expected to experience some kind of post-intoxication hangover syndrome if they drink enough of an alcoholic beverage. On the other hand, some appear to be relatively immune to any distinguishable or identifiable hangover. This phenomenon is most obvious among the heavy drinking population, as described in this paper and in a population of alcoholic patients described in a parallel report I151. It appears that, overall, of the heavier drinkers and the alcoholics, even though they consume very large amounts of alcoholic beverages such as red wines or whiskeys that are known to be associated with hangover, more than 50% of them do not report any morning after or post-intoxication hangover however this is defined, that is, as headache, nausea and vomiting, or tremors, or guilt and fatigue, or thirst. What the factors are that make some individuals less sensitive to hangover than others remains to be discovered. Others  have noted that although hangover headache can be a problem for the periodically excessive ‘social drinker’, it is not commonly suffered by the eventual alcoholic. These observations suggest that there may be a specific population of individuals for whom the absence of hangover susceptibility may make them appreciably more vulnerable to heavy drinking or alcoholic drinking than other individuals, all other things being equal. The present scaling of intensity of hangovers leaves much to be desired since the degree of incapacitation that is experienced by some individuals is markedly different from that of others. Some may actually be incapable of even walking or crawling, whereas others may experience only a short period of mild stomach upset or mild headache. Some experience dry heaves, that is, the compulsive, repetitive vomiting persisting long after the stomach and upper small intestine have been exhausted of their contents. A major challenge for future research is to develop better scales not only of the qualitative characteristics of the post-intoxication hangover syndromes(s), but also scales of the intensity of these signs and symptoms. The results of the factor analysis in the present study further emphasize the diversity of the kinds of hangovers that are experienced. At least three
different clusters of symptoms could be differentiated and scored in a fashion that indicated that they are relatively independent. The most commqn and unique of the symptoms is headache (Factor 3), followed by nausea and vomiting (Factor 2). These two seem to be the hallmarks of the hangover experience. It also should be pointed out that the presence of headache is clearly a distinguishing feature of the hangover, as compared with the withdrawal syndrome. Of all of the alcoholic patients in withdrawal studied in the report of Pristach et al. 1151,none reported headache. In contrast, among the present adult general population sample, headache was the single most common symptom experienced by almost 80% of the respondents. Moreover, looking at this phenomenon from the other direction, approximately one-fourth of the individuals had hangovers limited to Factor 3, that is, headaches only, with an additional one-fourth, approximately, that had headaches as well as nausea and vomiting. On the other hand, the Factor 1 symptoms of shaking hands, nervousness, and depression alone are relatively uncommon, but they are relatively frequently associated in those who have other kinds of hangovers and who consume larger amounts of alcohol. The tabulation of the category of hangover and intensity corresponds to previous reports in the literature. For example, headaches were the most common and accounted for most symptoms (41%) in a recent report , followed by gastrointestinal symptoms, whereas anxiety and tremor were found in less than 8% of the overall population. Also, our results were similar to the observations of Harburg et al. 1311that more than 30% of the population, even of relatively heavy drinkers, do not experience hangovers or, if they do, the hangovers are relatively mild. Furthermore, of their population of almost 1300 drinkers who reported getting drunk, 20% had never experienced a hangover! In this population study, it was not easy to detect any relationship between the type of beverage usually imbibed and the different frequency or quality of hangovers. This was in part due to the very small numbers, after controlling for amount. We anticipate that beverage type will be important on the basis of prior reports. For example, in comparing the post-intoxication consequences of whiskey with vodka, for equivalent amounts of alcohol, whiskey has been found consistently to be more likely to be followed by hangover of some type [4,10,33-41]. All of these reports together, although apparently accurate, represent the survey of only a limited number of individuals serving as volunteers. The distribution of sensitivity to hangover in the population has apparently not been addressed prior to the present study. Moreover, the studies on beverage type are limited to single exposure to a specific sample of a class of beverage. For example, the short report by Pawan  found hangover in 20 male subjects to be worse with rum or brandy, whiskey or red wine; the least hangovers followed vodka, gin or white wine, in that order; yet he
only tested one sample of each beverage type; different brands or sources probably vary appreciably as well. Thus, there is no doubt that the congeners play a necessary, but not the sole, role in the production of hangovers. Whether individuals have unique susceptibilities to hangover-producing substances, such as the various congeners , is not known. Furthermore, it is evident that alcohol without congeners as vodka results in hangovers in some individuals. In this study beverage preference was based on the beverage which accounted for the greatest proportion of the respondent’s average daily ethanol score. However, the number of heavier drinkers in this area who preferred beverages other than beer was so small that it was not possible to make a reasonable comparison. With this population at least, it will be essential to include oversampling for individuals who have beverage preferences other than beer. The present study sought data regarding the prevalence of hangover as well as the nature of the hangover syndrome, at least with respect to certain of the most prominent signs and symptoms in the general population and to relate these to drinking histories, beverage preference and drinking practices. Although it was not directed to investigating the physiological mechanisms responsible for the hangover, some clues as to the mechanisms would be welcome since detailed experimental inquiry has yet to uncover specific pathophysiologic mechanism(s) [lO,lll. The only well established mechanism is the plausible explanation of the nausea and vertigo based on the differential distribution of alcohol in compartments of the vestibular system in the inner ear [141. Changes temporally concurrent with hangover include the following: (a) There is a decrease in EEG alpha activity, an increase in theta, a statistically significant increase in 7-3 Hz. The EEG changes are not correlated or due directly to changes in concurrent blood alcohol level, acidosis, hypoglycemia, or fatigue 1431. &I) Plasma arginine vasopressin is increased [ill. (c) Auditory-evoked responses to a series of click stimuli were depressed during hangover, as well as during acute alcohol intoxication. No evidence could be found for a hyperexcitability of peripheral sensory systems during hangover . (d) Factors specifically examined in a series of studies that have been concluded as not directly involved in hangover include acidosis, hypo- or hypercalcemia, hypokalemia, hyperventilation per se, increased fatty acids, or major shifts in amino acids or acetaldehyde 15-121. Although the most severe hangovers were found in subjects with the lowest urinary calcium excretion and the lowest initial CAMP excretion 1121, the susceptibility to hangover was not directly related to calcium and magnesium metabolism. A biphasic effect on calcium excretion was observed, consistent with a number of previous studies; and there was not a clear relationship between either intoxication or withdrawal and the calcium and
magnesium levels and excretion. In spite of these rather variable results, it remains possible that hypomagnesemia or a low level of magnesium intracellularly, are among the critical factors in the manifestation of either intoxication or hangover. Clearly needed are more studies, especially those which measure tissue concentrations as well as blood levels. (e) As in experimental animal studies the catecholamine elaboration and secretion in man has been found not only increased during acute intoxication by ethanol, but also increased during the post-alcohol periods of hangover 1451as well as during the withdrawal after chronic administration 146,471. Not only is the epinephrine excretion increased, there is an elevation in corticosteroids 1451. 0’) Among the concomitants of hangover is hypoglycemia due, if for no other reason, to decreased food intake [e.g. 481; however, it is not a major cause of hangover symptoms. The administration of fructose or glucose failed to produce any significant changes in blood alcohol, acetaldehyde, psychomotor performance or hangover in an explicit and extensive series of experiments 1491. (g) The gastrointestinal symptoms during hangover are associated with clearly observable increases in mucous secretion and hypermotility as measured by direct endoscopic examination. After the ingestion of alcohol, the stomach became calm and relaxed 1501. Although there are no significant changes in plasma electrolytes that can causally correlate with hangover, there is a decrease in the output of urine that appears to compensate approximately for the diuresis that frequently accompanies intoxication. Along with this decrease in urinary output during hangover there are increases in the concentration of sodium and potassium, and these occur without any apparent hemoconcentration [11,511. Part of this effect of alcoholic beverages on urinaryelectrolytes is due to congeners, at least in the case of wine 1521. It needs to be pointed out that the hangover syndrome is a complex one and there are probably a number of factors contributing to specific symptoms, such as headache. The hangover headache may be mild, excruciating, dull, or more often, pulsating. Characteristically, it is throbbing and aggravated by movement of the head. It is not directly associated with the acute vasodilation produced by alcohol, since that vasodilation precedes the headache by many hours. Such headaches are obviously contributed to by susceptibility to migraine, a syndrome extremely similar to the hangover syndrome, by the so-called weekend headache, by the cafIeine withdrawal that may occur with a drinking binge, as well as by the disruption of sleep and potential period of hypoxia due to partial respiratory obstruction and/or excessive levels of carbon monoxide. Thus, the hangover and its headache and its nausea and vomiting are plausibly the result of all, or of one or more of the following: ethyl alcohol; alcoholic congeners in the beverage; carbon monoxide and hypoxia; stress and loss of sleep; the withdrawal of the usual caffeine intake; excessive or unusual consumption of foodstuffs and drink.
This line of reasoning raises the question of the possibility of a ‘toxic substance’ being generated by alcohol or its beverage congeners as a prime responsible agent for hangover or the withdrawal syndrome. Such a potential has been explored further in a review 1531 and is supported by the one report that hemodialysis may reduce hangover or withdrawal , by the fact that the withdrawal is absent in goldfish immersed in a large fluid medium, and that a withdrawal syndrome appears in both the rostra1 and caudal portions of animals with a chronic spinal cord transsection [53,55,56]. Although we are inclined to the more physical and biological basis for the hangover syndrome, it is recognized that the nature and severity of hangovers may not only be governed by biochemistry, but in large part by one’s attitude, prior experiences and psychological state 130,311. Male psychiatric inpatients who had ‘negative attitudes toward alcohol’ were found to experience more frequent and severe hangovers, irrespective of the amounts they had drunk, than those who had more favorable attitudes toward drinking . This was interpreted as indicating that the severity of the respondents’ hangovers was in a way the consequences of their attitudes toward drinking. Alternatively, it is plausible that the negative attitudes toward drinking were the result of having experienced severe hangovers. This was rejected as an unlikely explanation because age and attitudes were not found to be related and, presumably, the older one was the more profoundly fixed would be the attitudes [30,31]. The basic contention is that hangovers are primarily the property of those who drink ‘with guilt’. Yet, it remains important to develop the relationships between individuals’ beverage types, amounts and patterns of drinking with the hope of defining the relationships between the symptomatology, the intensity and the prevalence of symptoms. A serious confounding aspect of survey and anecdotal data remains the historical biases. One’s beverage preference, even to specific brands, is strongly correlated with social economic class and group, even within a given geographic area, with ethnic backgrounds, with drinking styles, as well as with the total amount of alcohol that is consumed at a time and over a period of a time. The present study was unable to tease out the differences that may well occur over time in a given person’s drinking career with reference to hangover. It would seem plausible that the symptoms that more closely resemble those of withdrawal, i.e., hands shaking, nervousness, disturbances of sleep, jumpiness, diarrhea, hot and cold flashes, sweating, depression, and anxiety, were experienced by the heavier drinkers and those who probably had the longer history of drinking. In such individuals it seems to be impossible to distinguish between overt or incipient withdrawal from a post-intoxication hangover. In this context, the distinction may largely be an artificial or semantic one since the mechanisms of either syndrome may be similar although they are not, as yet, well understood. Mendelson and Mello 1571 have emphasized that the traditional belief
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