Alcohol withdrawal symptoms: What are the early signs of alcohol withdrawal?

Overview: What does alcohol withdrawal feel like?

Alcohol withdrawal happens when a person stops drinking after a long period of chronic or heavy drinking. What does it feel like? For many people, mild withdrawal symptoms begin within six hours of the last drink. Once the alcohol is stopped, the brain gets overly excited. The first symptoms may be relatively mild: hands start shaking, blood pressure increases, reflexes become overactive, the heart begins fluttering, the stomach hurts, the head hurts, and people feel anxious and nervous. The symptoms could worsen as the hours pass. Convulsions and hallucinations can happen. People can feel confused or disoriented. Severe alcohol withdrawal is called delirium tremens, a several-day alcohol withdrawal syndrome in which people hallucinate, lose touch with reality, and get hyper-agitated. The heart races, the body temperature increases, and people begin to sweat. The worst possible outcome is respiratory depression, cardiovascular collapse, and death.

What are the early signs of alcohol withdrawal?

The earliest signs of alcohol withdrawal are mild symptoms that typically begin within six hours of the last drink. These include:

• Headache

• Stomach ache

• Hand trembling

• Anxiety

• Insomnia

• Heart palpitations

RELATED: What happens when you stop drinking?

Other alcohol withdrawal symptoms

As the hours go by, alcohol withdrawal symptoms often worsen, depending on a person’s history of severe withdrawal symptoms, seizures, or other illnesses.

There aren’t necessarily “mild” or “severe” withdrawal symptoms. Healthcare professionals determine the severity of alcohol withdrawal by scoring the severity of symptoms, including:

• Headache

• Nausea and vomiting

• Hearing disturbances

• Agitation

• Sweating

• Visual hallucinations

• Tremors

• Sensory “clouding”

• Disorientation

• Anxiety

Most of these symptoms are graded on a seven-point scale, with 0 as symptom-free and seven as the worst. While there are other symptoms, the “score” for these symptoms will determine the severity of the withdrawal and the appropriate treatment. If the score exceeds 15, the symptoms are severe and medical treatment is urgently needed.

The worst outcome of alcohol withdrawal is delirium tremens, which is potentially fatal. For people who are not healthcare professionals, delirium tremens can be recognized by:

• Confusion

• Hallucinations

• Disorientation

• Shaking

• Seizures

• Very high blood pressure

• Racing heart

• Agitation

• Irritability

• Slow or shallow breathing

Delirium tremens is a medical emergency and requires medical treatment to control the symptoms.

Although some people consider cravings to be a sign of alcohol withdrawal, substance abuse specialists consider cravings to be a common sign of dependency, no matter what the withdrawal status.

Alcohol withdrawal vs. hangover symptoms

Hangovers and alcohol withdrawal are two distinct physiological processes. As most people know, a hangover occurs after someone drinks too much at one time. Alcohol withdrawal is due to changes in the brain’s chemistry due to chronic drinking. Alcohol slows down the brain. If alcohol is regularly ingested, the brain compensates by not producing the chemical neurotransmitter it uses to slow down the brain. When alcohol is discontinued, the brain can’t produce enough of this “slowing down” neurotransmitter to control the central nervous system, resulting in the brain getting overly excited. The brain needs a few days to more than a week to readjust its proper chemical balance. 

On the other hand, no one knows exactly what causes a hangover. The best guesses are that it’s a build-up of toxins in the blood or the immune system overreacting. Some of the symptoms are the same, but hangovers do not last for days and progress into a serious threat to health and life.

SOURCE: Hangovers, National Institute on Alcohol Abuse and Alcoholism (NIH)

Stages of alcohol withdrawal 

Medical professionals determine the stages of alcohol withdrawal based on how bad the symptoms are. They use a 10-symptom scoring system called the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) scale. The score determines if the withdrawal is mild, moderate, or severe, and if a patient is in the early, middle, or late stages. With treatment, people with alcohol withdrawal usually don’t get worse. People who are not healthcare professionals can use a similar system. As alcohol withdrawal proceeds, the symptoms get worse. The appearance of symptoms like visual hallucinations, auditory hallucinations, tactile hallucinations, high blood pressure, and slowed breathing are all signs that medical treatment is needed before things get worse.

When to see a doctor for alcohol withdrawal symptoms

Alcohol withdrawal can and often does worsen. If it gets severe enough, alcohol withdrawal can be life-threatening. For this reason, it is always a good idea to get medical advice from a doctor when you or a loved one shows symptoms of alcohol withdrawal. If treatment starts even in the mildest phase, it’s possible to avoid the worst symptoms. Remember: the key identifier is the presence of symptoms that appear when someone suddenly stops chronic heavy drinking. It’s very likely that the symptoms they experience are alcohol withdrawal and not a hangover. If the symptoms are very bad—especially if the person is hallucinating, delirious, confused, disoriented, or slow breathing—get emergency medical help.

Doctors diagnose alcohol withdrawal based on the patient’s history of alcohol dependence, time since the last drink, history of alcohol withdrawal, history of seizures, detox history, history of liver disease, and the severity of the symptoms. Doctors primarily diagnose alcohol withdrawal by using a symptom-scoring system to determine how severe the withdrawal is and what medications are needed. They may also perform a blood test to determine alcohol levels in the blood. People who are delirious or are showing unusual symptoms may be tested for toxic alcohols, such as antifreeze or rubbing alcohol. 

Complications of alcohol withdrawal

The most serious complications of alcohol withdrawal are:

• Withdrawal seizures

• Visual, auditory, or tactile hallucinations

• Profound confusion

• Delirium tremens

• Respiratory depression

• Respiratory arrest

• Cardiovascular collapse

• Death

About 3% to 5% of people experiencing alcohol withdrawal symptoms show the most severe symptoms. Among people who are heavy drinkers, the lifetime incidence of delirium tremens is 5% to 10%. About 5% of people diagnosed with delirium tremens die.

INCIDENCE SOURCE: Delirium tremens, StatPearls

How to treat alcohol withdrawal symptoms

It’s best to not treat alcohol withdrawal at home, though mild cases are often treated with outpatient care. Healthcare providers treat alcohol withdrawal by either providing supportive care or temporarily slowing down the brain with central nervous system depressants. If a physician determines that the symptoms are mild and there’s little risk that they’ll get worse, treatments usually involve supportive care like rehydration and electrolytes. People at risk of worsening symptoms may be given gabapentin or an anticonvulsant and treated in an inpatient setting. More severe symptoms are treated with drugs that cause sedation, such as benzodiazepines (diazepam, chlordiazepoxide, or lorazepam) or barbiturates.

Signs alcohol withdrawal is getting better

People experiencing alcohol withdrawal will get better. The brain needs time to start functioning normally. That usually takes about a week, but it could take up to two weeks. How do you know it’s getting better? The symptoms will get better. As the brain returns to its normal ability to keep the nervous system under control, symptoms will gradually improve and fade. The worst of it typically peaks between one and three days after the last drink. 

FAQs about alcohol withdrawal symptoms

When do alcohol withdrawal symptoms start?

Alcohol withdrawal typically starts within hours of the last drink.

How long do alcohol withdrawal symptoms last?

Alcohol withdrawal typically lasts a week or slightly longer. The worst symptoms are experienced one to three days after the last drink. However, once symptoms are over, the underlying problem, alcohol-related substance use, has not been solved. Get appropriate addiction treatment, such as Alcoholics Anonymous or other support groups.

Which medication is used to prevent alcohol withdrawal symptoms?

Alcohol withdrawal is treated with supportive care and CNS depressants, such as gabapentin, anticonvulsants, benzodiazepines, and, in the worst cases, barbiturates.

What’s next? Additional resources for people with alcohol withdrawal symptoms

Test and diagnostics

• Delirium tremens, StatPearls

• The ASAM clinical practice guideline on alcohol withdrawal management, American Society of Addiction Medicine

• What happens when you stop drinking?, SingleCare

Treatments

• Alcohol withdrawal, StatPearls

• The ASAM clinical practice guideline on alcohol withdrawal management, American Society of Addiction Medicine

Scientific studies and clinical trials

• Alteration of glutamate/GABA balance during acute alcohol withdrawal in emergency department: a prospective analysis, Alcohol and Alcoholism

• Occurrence, predictors, and prognosis of alcohol withdrawal syndrome and delirium tremens following traumatic injury, Critical Care Medicine

More information on related health conditions

• Alcohol statistics 2022, SingleCare

• Hangovers, National Institute on Alcohol Abuse and Alcoholism (NIH)

• The most effective drugs to help you stop drinking, SingleCare