Alcohol Withdrawal Timeline: Symptoms and Duration

Alcohol withdrawal syndrome is experienced by approximately half the people with an alcohol use disorder who stop alcohol use abruptly. Alcohol withdrawal occurs within hours to several days of stopping heavy, extended alcohol consumption. Symptoms can be mild to life-threatening. Alcohol withdrawal treatments range from additional hydration to hospitalization to manage potentially fatal symptoms, including alcohol withdrawal seizures.

Alcohol Withdrawal

Alcohol is one of the most commonly used substances in the United States, with over 75% of people aged twelve and older having consumed alcohol at some point.[1] There is a spectrum of alcohol consumption from low-risk to severe alcohol use disorder. Alcohol withdrawal is a result of stopping prolonged and heavy drinking. In some cases, alcohol withdrawal symptoms are mild and manageable at home. However, there is a possibility to experience severe, life-threatening withdrawal symptoms that require emergency medical attention.

Acute alcohol withdrawal usually lasts between four to five days, with symptoms such as mild anxiety and gastrointestinal problems. More severe withdrawal symptoms occur in approximately 10% of cases and include symptoms such as autonomic hyperactivity, tremors, or alcohol withdrawal delirium.[2] About 3% of people experience tonic-clonic seizures. Severe alcohol withdrawal symptoms require medical treatment.

Diagnostic Criteria for Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome is diagnosed based on the cessation of prolonged and heavy alcohol use, and within hours to a few days of no longer drinking alcohol.[3] The following symptoms are typical of alcohol withdrawal syndrome:

• Autonomic hyperactivity (examples include sweating and a fast heart rate over 100 beats per minute)
• Increased hand tremor
• Insomnia
• Nausea or vomiting
• Transient visual, tactile, or auditory hallucinations or illusions
• Psychomotor agitation
• Anxiety
• Generalized tonic-clonic seizures

Signs of Alcohol Withdrawal

Common symptoms of alcohol withdrawal include alcohol cravings, nausea, vomiting, stomach pain, puffy and blotchy skin, and swelling in the arms, legs, feet, and hands.[4] These symptoms usually peak on the second day of not using alcohol and begin to subside on the fourth or fifth day of abstinence. Long-term withdrawal symptoms, also known as protracted withdrawal, can last for three to six months and include symptoms of anxiety, insomnia, and autonomic dysfunction.

Alcohol Withdrawal Timeline, Stages, and Symptoms

It is important to know the stages of alcohol withdrawal so you can be aware of what is typical to be experiencing and when you should seek medical attention.[5] The following five stages of alcohol withdrawal symptoms include:

Stage 1: Mild Withdrawal

6-8 hours from the last drink.

Symptoms include:

• Mild tremors
• Anxiety
• Nausea

Stage 2: Alcoholic Hallucinosis

12-24 hours from the last drink.

Symptoms include:

• Stable Vitals
• Tremors
• Agitation
• Insomnia
• Hallucination (auditory, visual, tactile), insight is maintained

Stage 3: Withdrawal Seizures

12-48 hours from the last drink

Symptoms are similar to stage two but are more severe:

• Stable Vitals
• Tremors
• Agitation
• Insomnia
• Hallucination — Visual hallucinations are most common, although auditory or tactile hallucinations can also occur. Unlike delirium tremens, the person may remain alert and aware that the hallucinations are not real.
• Seizures – between 10%-30% of people who have alcohol withdrawal syndrome experience alcohol withdrawal seizures.

Stage 4: Delirium Tremens

2-5 days from the last drink

Symptoms include:

• Unstable vitals
• Confusion
• Agitation
• Fever
• Tachycardia
• High blood pressure
• Excessive sweating

Delirium tremens, or alcohol withdrawal delirium, is the most severe level of alcohol withdrawal syndrome.[6] Delirium Tremens are serious and can be life-threatening. It has a 5% mortality rate.[7]

Symptoms include:

• Fever – high body temperature
• Tachycardia – fast heart rate
• Agitation – restlessness, irritability, anxiety
• Diaphoresis – excessive sweating
• Hallucinations – seeing, hearing, or feeling things that are not there
• Disorientation – mental confusion
• Hypertension – high blood pressure

Alcohol withdrawal delirium, also known as delirium tremens, is the most severe form of alcohol withdrawal. It typically develops within several days after a person stops drinking and can cause confusion, agitation, hallucinations, fever, rapid heart rate, and high blood pressure. Although only about 3% to 5% of people with alcohol withdrawal syndrome develop alcohol withdrawal delirium, the condition can be life-threatening and requires immediate medical attention.[8]

Stage 5: Chronic Alcohol Use

1-6 months from the last drink

Symptoms include:

• Autonomic hyperactivity
• Anxiety
• Sleep disturbance

Risk Factors

Some risk factors increase the likelihood of experiencing alcohol withdrawal syndrome.[9] These include:

• Being over the age of 30, the risk and severity of withdrawal symptoms increase with age.
• Taking other depressant medications (examples include anti-anxiety medications and medications that treat insomnia)
• Unrelated health conditions that occur alongside alcohol withdrawal delirium (examples include pneumonia, liver failure, head trauma, GI bleeding, low blood sugar, electrolyte imbalance, post-surgery). It is important to share with your medical provider your alcohol use history as part of your medical history or hospital intake.

Management Strategies and Treatment

For most people, alcohol withdrawal syndrome is mild and does not require medical attention. However, if you experience severe symptoms, seek medical attention immediately, as they can be life-threatening.

Depending on your symptoms and needs, treatment may occur in one of many options, including the emergency room, outpatient clinic, intensive care unit, detoxification facility, or inpatient clinic.

Mild symptoms of withdrawal can often be managed at home. You should drink plenty of fluids to flush the alcohol from your body and replace any fluids you may be losing through sweating and diarrhea. You should drink two to four liters of water a day throughout withdrawal.[10]

Consider taking a multivitamin, especially B vitamins, to address cognitive issues that are often experienced during withdrawal. Over-the-counter medications may also be taken to treat diarrhea, nausea, and headache symptoms.

Moderate symptoms can be managed with similar steps as mild symptoms. Your medical provider may also prescribe diazepam, which helps reduce the intensity of alcohol withdrawal syndrome symptoms.[11]

Severe symptoms require medical attention and should not be attempted to be managed at home. People with severe symptoms often require regularly administered and high doses of diazepam, along with other medications and supportive treatments, to manage their symptoms.[12] Supportive treatment can include intravenous fluids with magnesium and potations to treat severe dehydration. Other medications may be needed to treat extreme and fluctuating body temperatures and blood pressure, as well as seizures and hallucinations.

Reducing the Risk of Alcohol Withdrawal Syndrome

If you suspect you or a loved one has an alcohol use disorder, you should speak to your healthcare provider or enroll in an alcohol rehab before you stop drinking alcohol. They can work with you to create a treatment program that meets your needs and limits the possible withdrawal symptoms you experience.

Addiction healthcare professionals can also help you establish follow-up care after your medical detox. Sustaining abstinence from alcohol is extremely difficult. You should seek substance use recovery support and follow through with any additional referrals from your healthcare provider for physical and mental health assessments and treatment.

Frequently Asked Questions About the Alcohol Withdrawal Timeline