Hydroxyzine for Anxiety: How it Works, Side Effects, & More

What Is Hydroxyzine?

Hydroxyzine is a sedating antihistamine that belongs to the piperazine class of drugs.¹ Its FDA-approved uses include treating anxiety, itching, agitation, as a sedative before surgery, emotional stress, and tension.

The drug affects certain natural substances like acetylcholine and serotonin present in the body or acts directly on certain parts of the brain. Hydroxyzine is available under brand names such as Atarax (hydroxyzine hydrochloride), Vistaril (hydroxyzine pamoate), ANX, Hyzine, and Rezine. ^1,2

How Does Hydroxyzine Work?

Hydroxyzine rapidly absorbs from the gut after being ingested orally. Clinical improvement is usually apparent within 15 to 30 minutes. It works by blocking the natural substance called histamine that the body produces during an allergic reaction.¹ Hydroxyzine also increases serotonin levels in the brain, promoting better mental well-being and mood stabilization.

The maximum clinical gain occurs after 2 hours, with a duration of action of approximately 3 to 4 hours. It is safe to use in children, adolescents, and pregnant women. However, it tends to develop drug tolerance over time.³

Does Hydroxyzine Reduce Anxiety Symptoms?

Hydroxyzine is an FDA-approved drug used to treat anxiety symptoms.³ FDA approval can be granted for a drug proven to provide benefits that outweigh its known and potential risks for the intended population. Additionally, it has shown a lack of drug toxicity and an absence of dependency.⁴

Types of Anxiety Treated with Hydroxyzine

Hydroxyzine is used for the symptomatic relief of anxiety associated with psychoneuroses, generalized anxiety disorder (GAD), and as an adjunct in organic disease with anxiety. Hydroxyzine is the most studied antihistamine for GAD and the only antihistamine that is FDA-approved for GAD use. It is well-tolerated, aside from adverse effects like dry mouth, constipation, sedation, and risks of use while driving.³

Hydroxyzine Hydrochloride Vs. Hydroxyzine Pamoate for Anxiety

Hydroxyzine hydrochloride is the active ingredient in Atarax, a brand name that has been discontinued, but its generic version is still available in the US. On the other hand, hydroxyzine pamoate is the active ingredient in Vistaril, which is still available.

Atarax has few mild short-term side effects at higher doses, which may go away with dose reduction or continued treatment.⁵ In contrast, hypersedation, confusion, convulsions, nausea, and vomiting are some common side effects of Vistaril. Occasionally, it may also cause a fast heartbeat and skin eruptions.¹

Both drugs are FDA-approved and effective in treating anxiety, but their efficacy varies from person to person. Atarax is available in tablet and syrup forms, while Vistaril comes in capsules and liquid (suspension) forms.

How Effective is Hydroxyzine for Anxiety?

Hydroxyzine has been proven to be an effective and safe treatment for symptoms of generalized anxiety disorder (GAD). Researchers discovered that a daily dose of 50mg of hydroxyzine significantly reduces anxiety symptoms. This effect was observed during the first week of treatment and maintained throughout the four weeks of the study. Even after abrupt discontinuation, there was no rebound of anxiety or withdrawal symptoms.^6,7

For long-term use (four months), hydroxyzine’s effectiveness as an antianxiety agent has not been assessed in systematic clinical studies.

How Quickly Does Hydroxyzine Work for Anxiety?

Hydroxyzine is quickly absorbed from the gut and has a fast-acting effect. Its clinical effects are usually noticed within 15 to 30 minutes after ingestion.¹ It can be used as a supplementary medication with various other psychiatric drugs.

How Long Do the Effects of Hydroxyzine Last?

It takes about two hours for the maximum clinical effects of hydroxyzine to develop, and the calming effect can last for up to four to six hours after taking a dose.⁸ Never adjust the drug dose on your own.

Hydroxyzine for Anxiety Dosage

The recommended dose to relieve anxiety symptoms in adults is 50 to 100 mg four times daily. The dose is 50 mg daily in divided doses for children under six years, while for children over six years, the dose is 50 to 100 mg per day in divided doses. If the treatment is an injection, subsequent doses may be taken by mouth.

The dose depends on the person’s age, medical condition, and treatment response. In children, the dose depends on their body weight. It is important not to exceed the recommended prescribed dose. Inform your doctor if your symptoms do not improve or worsen.¹

What Is the Best Time to Take Hydroxyzine?

The best time to take the drug is at bedtime due to the potential side effect of sedation, which may lead to increased risk for falls, altered mental status (delirium), slowed breathing, and driving difficulties. It is expected that the sedative effect of hydroxyzine would be apparent in the night after an evening dose but less in the morning, making daytime functioning less affected.

Who Can Take Hydroxyzine for Anxiety?

Hydroxyzine can be used by the elderly, adults, and children relieving their anxiety symptoms. Generally, doctors prescribe low doses in the elderly and children to minimize the risks of over-sedation and arrhythmia driven by the drug. A doctor may adjust the hydroxyzine dose adjustment for people with heart, liver, and kidney diseases or taking drugs for other health problems.

Can Hydroxyzine Help Anxiety Daily?

Hydroxyzine can be taken daily or as needed, depending on how the person responds to it. You should take it at the same time every day, following the instructions on your prescription label. One unique feature of hydroxyzine is that it has a fast onset of action. Your doctor will determine the appropriate dosage and method of taking the medication based on your response to it.

Studies have shown that hydroxyzine can significantly reduce anxiety symptoms within a week of administration. However, its effectiveness as a long-term antianxiety agent has not been assessed by research studies. Therefore, the physician should periodically reassess the drug’s usefulness for the individual patient and adjust the dosage according to their response to therapy.⁷

Side Effects of Hydroxyzine for Anxiety

It is common for people to have side effects when starting hydroxyzine as their bodies adjust to the medication. Some people, however, may not have any side effects. The antihistamine physiologically changes the chemical processes in the brain, which can cause drowsiness.

Digestive side effects include nausea, vomiting, and constipation. Side effects of hydroxyzine are usually mild and may or may not be present for all people. Inappropriate timings, multiple sedative drugs, and frequent dose adjustments are some common factors that contribute to side effects.¹

Common side effects of hydroxyzine for anxiety include*:¹

• Dry mouth
• Headache
• Drowsiness
• Shakiness (tremors)
• Itching and rash

*All medications, including hydroxyzine, can cause side effects which can be mild or serious. This is not a comprehensive list of all possible side effects. You should talk with your doctor about any questions you have and to understand the potential side effects and benefits of any medication.

Serious side effects of Hydroxyzine for anxiety that require immediate medical attention include*:¹

• Fast and irregular heartbeat
• Trouble controlling body movements
• Severe dizziness
• Convulsions
• Feeling confused (hallucinations)
• Fever with bad skin rash and swelling (allergic reaction)

*All medications, including hydroxyzine, can cause side effects which can be mild or serious. This is not a comprehensive list of all possible side effects. You should talk with your doctor about any questions you have and to understand the potential side effects and benefits of any medication.

While rare, some people may have a higher risk of potentially life-threatening side effects like irregular heartbeats (QT prolongation, Torsade de Pointes) and severe allergic reactions (rash, hives, red, swollen, blistered, or skin peeling) when taking a drug. Get medical help right away if you have tightness in the chest or throat, trouble breathing, swallowing, or talking, and swelling of the mouth, face, lips, tongue, or throat.

Hydroxyzine Warnings

Hydroxyzine does not carry a black box label warning. Still, it should be avoided or used with caution in individuals with certain health conditions, such as heart problems, asthma, COPD, glaucoma (blurry vision), difficulty in urination, and an enlarged prostate.

It is recommended to avoid or use a lower dose in older adults due to the risk of oversedation and confusion, and close monitoring is advised.

Hydroxyzine may not be suitable for people who:

• Are pregnant or trying to become pregnant
• Nursing mothers
• Drivers
• Heavy machine operators
• Older adult
• A skin disease called acute generalized exanthematous pustulosis (AGEP)
• Blurry vision (glaucoma)
• Lung disease (asthma or COPD)
• Heart diseases (QT prolongation, Torsade de Pointes)
• Enlarged prostate and trouble passing urine
• Alcoholics and narcotics

Drug Interactions With Hydroxyzine

Disclaimer: Taking certain medications, herbs, or supplements alongside hydroxyzine can change how hydroxyzine works in your body or increase the risk of serious side effects. This article does not consider all the possible interactions. Please let your doctor, psychiatrists, and pharmacists know about all the products you currently use, such as prescription medication, nonprescription drugs, and herbal supplements. Do not start, stop, or change the dosage of any medicines without your doctor’s approval.

Drug interactions occur when two drugs that are taken either together or within a short time of each other affect each other’s action.. One drug affects the absorption, distribution, metabolism, or excretion of another drug. Hydroxyzine can interact adversely with a range of other medications, including those in the list below.

Medications that can interact with hydroxyzine include:^1,9

• Other antihistamines: Caution is recommended due to the risk of rapid heartbeat when diphenhydramine (Benadryl) and cetirizine (Zyrtec) are combined with hydroxyzine.
• Benzodiazepines: Benzodiazepines have anxiolytic, hypnotic, anticonvulsive, and muscle-relaxing properties. They are primarily used for anxiety and insomnia (poor sleep). Using hydroxyzine may enhance the depressant effects.
• Barbiturates: They are used as a general anesthetic for sedation. When used with hydroxyzine, an enhanced depressant effect or excessive sedation may occur.
• Benztropine (Cogentin): This medication treats Parkinson’s disease. It may increase the heartbeat when combined with hydroxyzine.
• Zolpidem (Ambien): This medication is used to treat sleep problems. It may increase the depressant effects when combined with hydroxyzine.
• Drugs that increase heart rate: Caution is recommended when quinidine, procainamide, amiodarone, sotalol, amitriptyline, methadone, antipsychotics, and antibiotics are used with hydroxyzine due to rapid, irregular heart rate.

Is Hydroxyzine Habit-forming?

Hydroxyzine is not a habit-forming drug. It is a nonaddictive and sedating antihistamine with benefits for poor sleep (insomnia) in GAD. Specialists may use serotonergic reuptake inhibitors (SRIs) with hydroxyzine for people with a history of substance use disorder.^4,7

How to Get a Prescription for Hydroxyzine for Anxiety

Hydroxyzine is generally prescribed by a primary care physician, physician’s assistant, nurse practitioner, or psychiatrist for anxiety disorder. An online psychiatry service offers care comparable to an office visit and can be a more suitable option for some people.

Additional Strategies to Enhance Hydroxyzine Treatment for Anxiety

Successful treatment strategies typically involve combining hydroxyzine with psychotherapy. For individuals with suboptimal response (partial or no response) to initial drug management, doctors suggest adjunctive cognitive-behavioral therapy (CBT). CBT commonly involves a problem-solving approach.¹⁰

Other psychotherapies, such as relaxation therapy, supportive psychotherapy, or mindfulness therapy, have been used if CBT is not appropriate.¹¹ In most cases, combining psychotherapy and drug treatment may substantially improve the quality of life in individuals with GAD.¹²

Alternative Treatments for Anxiety

There is some evidence that combining psychotherapy and drugs may be more effective than either treatment alone. Cognitive-behavioral therapy (CBT for anxiety), exposure therapy, online group therapy, support groups, antidepressants, and anti-anxiety drugs have all been shown to be helpful.

Research generally shows that psychotherapy is more effective than drugs and that adding drugs may help temporarily reduce anxiety symptoms but does not significantly improve outcomes from psychotherapy alone.

Therapists may use several aspects of CBT, like self-monitoring, relaxation training, problem-solving, time management training, and goal setting. These can help a person reduce feelings of uncertainty that may lead to anxiety while increasing a person’s ability to cope with their anxiety symptoms.

Alternative treatments for anxiety include:

• Selective serotonin reuptake inhibitors (SSRIs): SSRIs are generally used as first-line treatment for GAD. They are effective, well tolerated, and have less sedation, mental side effects, and risk of dependence than other antianxiety drugs.^3,13
• Serotonin-norepinephrine reuptake inhibitors (SNRIs): SNRIs are also the preferred initial treatment of GAD. It increases the amount of serotonin and norepinephrine (noradrenaline) neurotransmitters in the brain, regulating arousal and alertness.³
• Buspirone: Buspirone belongs to a group of drugs called azapirones and is considered a second-line drug for GAD when a person does not respond well to SSRIs. Buspirone works well when there are high levels of worry, tension, irritability, or a mix of depression and anxiety.^3,14
• Gabapentin: Gabapentin has been prescribed off-label for anxiety and can be used who show a partial response to initial treatment with SRIs. It reduces the release of excitatory neurotransmitters, which can result in a calming and sleepy effect.³
• Pregabalin (Lyrica): Lyrica may be prescribed off-label for anxiety and insomnia. This medication can also be used to treat sleep problems, which are common in people with anxiety disorders. However, it has a greater potential for addiction and dependence.³
• Cognitive behavioral therapy: CBT is a set of techniques and a skills-based approach to modify maladaptive thinking patterns and acting to alleviate emotional symptoms. CBT for anxiety uses reasoning exercises or real experiences to reduce anxiety and improve quality of life.
• Exposure therapy: Exposure therapy is a psychological treatment to help people reduce their fears by creating a safe environment to expose individuals to the feared objects, activities, or situations they fear and avoid. Exposure techniques help people cope with real-life anxiety-provoking situations with less avoidant behavior. Relaxation techniques and cognitive skills help cope with anxiety.¹⁵
• Complementary and alternative medicine (CAM) therapies: These mind-body therapies combine mental focus, breathing, and body movements to help relax the body and mind. Meditation is a focused breathing or repetition of words or phrases to quiet the mind and lessen stressful thoughts and feelings.^16,17
• Biologically based practices: Research suggests that herbal products like kava and chamomile may reduce anxiety in people with GAD. A person may feel calm using a diet containing vitamins, minerals, and herbs like turmeric or cinnamon to help their body heal.¹⁷ These are not proven treatments and should only be used after consultation with a doctor.
• Group psychotherapy: Online group therapy or support group offers supportive networks for people with similar difficulties. Cognitive, psychodynamic, supportive, and psychoeducational techniques may be used.¹⁸

Questions to Ask Your Healthcare Provider About Hydroxyzine for Anxiety

Under medical guidance, hydroxyzine is generally safe, and side effects typically reverse once the person stops taking the medication. Asking your prescriber questions can help you better understand your treatment process, including any benefits and risks of medication.

Questions to ask your care team when considering the side effects of hydroxyzine may include:

• Can I use hydroxyzine along with therapy to treat anxiety?
• How long will it take for me to adjust to taking hydroxyzine?
• Am I at risk for more severe symptoms if I am already taking other anxiety /depression medications?
• What is the best dosage to ensure fewer side effects?
• Are there drugs I am taking that could have negative interactions?
• How soon will I experience the side effects after starting a hydroxyzine dose?
• When should I reach out to you right away if I am experiencing side effects?
• Is there anything I should tell my therapist about this new medication?
• What are the risks if I take hydroxyzine for a longer duration?
• Are there specific concerns about hydroxyzine during pregnancy and breastfeeding?
• What are the common factors that enhance the risks of hydroxyzine side effects?

In My Experience

In my experience, hydroxyzine has been effective in managing panic attacks, disturbed sleep, and other anxiety-related symptoms. Unlike opioids and benzodiazepines, hydroxyzine is non-habit-forming and relatively safe. Therefore, it can prevent the extensive use of medications with a risk of dependence and sedation. Although hydroxyzine is a second-line intervention for anxiety, it is an option for individuals who do not respond to standard antianxiety medications.

For Further Reading

• Stage Fright: Definition, Causes, & How to Get Over It
• Options for Anxiety Therapy
• Hydroxyzine (Atarax® or Vistaril®): Important Patient Information
• Gabapentin for Anxiety: Uses, Dosage, Side Effects, & More
• Hydroxyzine Vs Xanax for Anxiety: How Do They Compare?