Disclaimer: None of the information in this article constitutes medical advice. All statements are merely the opinion of the writer(s). We recommend that patients follow their doctor’s guidance in regard to prescription medication.
Hydroxyzine, often referred to as hydroxyzine hydrochloride/HCL (tablet and liquid version) or hydroxyzine pamoate (capsule and liquid version) is a prescription antihistamine medication approved for the treatment of anxiety by the Food and Drug Administration (FDA). Most anti-anxiety drugs we've reviewed on Illuminate Health are selective serotonin reuptake inhibitors (SSRIs), so it's unique that an antihistamine can treat anxiety.
But is hydroxyzine as effective as more standard anxiety medications? Does it have any dangerous side effects? Can the drug treat sleep disorders as well? And how do real users respond to hydroxyzine treatment?
In this article we'll answer all of these questions and more as we review clinical studies on hydroxyzine to determine if it's safe and effective for treating anxiety and sleep disorders. We'll document side effects of the drug, explain whether the branded version is more effective, and share a real, unsponsored user's review of hydroxyzine.
Does Hydroxyzine Reduce Anxiety?
Hydroxyzine has been approved by the FDA since 1956, so there are a vast number of clinical trials testing its effectiveness for anxiety reduction.
A clinical trial of hydroxyzine for anxiety found that at a daily dose of 50 milligrams (mg), it was more effective than placebo to a statistically significant degree, both after 1 week and after 4 weeks.
A more recent medical review published in the Evidence-Based Practice journal evaluated five different trials on hydroxyzine for anxiety. The researchers found that hydroxyzine was more effective for generalized anxiety disorder than placebo, and was similarly effective to other first-line treatments such as benzodiazepines (benzos).
It’s important to note that most of the medical research proving hydroxyzine’s effectiveness is on patients with generalized anxiety disorder, which is one of the less severe forms of anxiety based on medical classification.
We only located one clinical study evaluating hydroxyzine for panic disorder. It was a case report, meaning the study documented the positive effect of the treatment on one patient. The patient was administered hydroxyzine while actively experiencing a panic attack, and the drug not only caused the panic attack to subside, but the patient didn't experience panic attacks for over a month after that one single dose.
While this is useful information, we don’t believe it’s enough data to suggest that hydroxyzine is effective for panic disorder overall.
We can conclude from the above-linked research that hydroxyzine is effective for providing anxiety relief.
Does Hydroxyzine Cause Side Effects?
Like most pharmaceutical medication, hydroxyzine carries a risk of side effects that patients and their doctors have to balance against the benefits.
Medical research has compared the side effects of hydroxyzine against placebo. Overall side effects were reported in 52% of hydroxyzine patients versus 35% of patients taking placebo, suggesting a "real" side effect rate of 17%.
Sleepiness was 14% more common in the hydroxyzine group, weight gain was 2% more common and dry mouth was 9% more common.
The benefit of hydroxyzine compared with more common types of anxiety medications like SSRI is that its side effect profile seems relatively mild. The FDA label even notes that side effects reported with use of hydroxyzine are “usually mild and transitory in nature.”
Hydroxyzine carries no “black box” label warning, which is a warning required by the FDA on labels of medications with serious side effect risks, and this type of warning is quite common in anxiety medications. Our Zoloft reviews article highlighted how that medication, which is often prescribed for anxiety and panic disorders, carries a black box warning indicating it can increase suicide risk.
Overall it appears that hydroxyzine’s side effect profile is much less concerning in comparison with other popular anxiolytic (anti-anxiety) medications.
Real, Unsponsored User Review of Hydroxyzine
A YouTube creator named Torie Brame published a video explaining her experience on hydroxyzine. She shares advice about when not to use the drug, and explains benefits and side effects that she experienced.
The video is only five minutes long and is unsponsored:
Does Hydroxyzine Interact With Alcohol?
Patients are often curious about whether hydroxyzine has a negative interaction with alcohol or requires that users abstain from alcohol use, given that some anti-anxiety drugs have this interaction.
While the drug's FDA label does not state that alcohol use must be stopped while on the drug, it cautions that "the effect of alcohol may be increased." This suggests that hydroxyzine has a potentiating effect on alcohol, and that users should avoid driving or operating any heavy machinery after using both hydroxyzine and alcohol.
Given this warning, we would recommend that patients with alcohol use disorders or even moderate alcohol use speak with their doctor about alternative anxiety drugs that do not interact with alcohol.
Does Hydroxyzine Improve Sleep?
As we reported in the side effects section of this article, hydroxyzine may increase sleepiness. Taking hydroxyzine to treat sleep disorders is an off-label use of the drug.
While there are a few case reports and studies of hydroxyzine for insomnia in very specific circumstances, there doesn’t appear to be any research proving it’s effective for healthy patients with insomnia.
A review of pharmacotherapy for insomnia reported in regard to hydroxyzine for sleep that “there are few data to support its efficacy or safety for this indication.”
We tend to recommend melatonin as a first-line treatment for sleep, because it’s extremely safe and non-toxic as we highlighted in our is melatonin safe article. Patients with more extreme sleep disorders may necessitate a prescription sleep medication, but patients with minor sleep disorders should speak with their doctor about melatonin (which does not interact with hydroxyzine according to the drug's label).
Is Brand-Name Hydroxyzine More Effective?
Hydroxyzine is the name of the generic drug, and the branded version is called Vistaril.
As we referenced in our Vistaril reviews article, we typically recommend that patients speak with their doctor about the generic version of a drug. An extensive medical review published in the PLOS Medicine journal compared the effectiveness of generic versus brand-name drugs, and concluded that generic drugs were equally effective.
This result is unsurprising given that generic and brand-name drugs have the same active compound, but it's useful to see it confirmed in clinical research. This suggests that hydroxyzine should be just as effective as brand-name Vistaril, but may be cheaper.
According to StatPearls, which is a free medical database maintained by the National Library of Medicine, hydroxyzine's dosage for adults typically ranges from 25 mg to 100 mg, and is taken in three to four daily doses. This equates to a total daily dose range between 75 mg and 400 mg.
Those prescribed hydroxyzine for allergies may use a dose lower than 75 mg.
Typically, a doctor will prescribe a dose on the lower end of the range (like 100 mg total daily dose) to test the patient's response. If the patient responds favorably to a relatively low dose, this will not only be cheaper for the patient in the long run but will minimize the risk of side effects, because that risk tends to scale with dose.
How Does Hydroxyzine Work?
It’s important for patients to understand how their medications work.
While researchers haven’t entirely confirmed hydroxyzine's mechanism of action, it’s been suggested that the drug is an antagonist at receptors in the brain that influence serotonin metabolism.
Serotonin is a neurotransmitter that influences mood and sedation, so patients with anxiety disorders often have irregular metabolism of this compound, and hydroxyzine seems to normalize this process.
The above-linked medical review suggests that hydroxyzine’s anti-anxiety activity is also caused by its “suppression of certain subcortical regions.” This suggests that overactivity in these regions contributes to the patient’s anxiety.
Our Mental Wellness Platform Recommendation
We recommend a platform called Brightside to patients dealing with mental health issues. It's an online therapy and medication platform that connects patients with licensed doctors and therapists from the comfort of their home.
A medical review published in the Clinical Psychology & Psychotherapy journal found that online therapy was equally effective to in-person therapy for treating depression, anxiety and PTSD. Therapy may be a good first option for patients who want to avoid the side effects of medication.
Brightside also can connect patients with licensed psychiatrists that can prescribe medication. Some patients choose only therapy, some choose only medication, and some choose both. The brand reports that 86% of members feel significantly better within 12 weeks of treatment.
Patients with and without health insurance can use Brightside. For many patients with health insurance, treatment is entirely covered by insurance.
The cost for medication without health insurance is capped at $95/month and the cost for therapy without health insurance is capped at $299/month.
Interested patients can check out Brightside at this link to the brand's website.
Hydroxyzine User Reviews
Hydroxyzine has been reviewed over 1,200 times on Drugs.com at the time of updating this article. This website allows prescription medication users to rate their experience on a drug.
The current average rating of hydroxyzine for anxiety is only 5.5 out of 10 which is relatively unimpressive.
The top positive review of hydroxyzine for anxiety comes from a user named "Nini" who claims the drug was more effective than Xanax:
"This drug hydroxyzine has been amazing for me and my anxiety. Xanax is way too strong for me, makes me feel like a zombie. Hydroxyzine helped me immediately to feel calm, in control and rational. It has been a life saver. I am so glad it exists."
The top negative review of hydroxyzine for anxiety is written by a user named "paintballjord" who claims that the drowsiness caused by the drug worsened their quality of life:
"It is just a strong antihistamine. It literally sucks the life out of me. It helps my anxiety simply by the fact I'm not thinking about my anxiety because of how miserably tired I am all day. I'd rather have 6 attacks a day than have simply walking to the bathroom make me need to sit and catch my breath (I am 6'2' and 160 lbs, I keep in good shape, simply breathing and walking should not make me need to catch my breath)."