Is Hydroxyzine or Xanax Better for Treating Anxiety?
Key takeaways:
Hydroxyzine (Atarax, Vistaril) and alprazolam (Xanax) are two commonly prescribed anti-anxiety medications.
Both medications kick in quickly and share some common side effects, such as drowsiness and dry mouth.
Alprazolam — especially high doses — can be habit-forming, but hydroxyzine does not have this risk.
Feeling nervous or scared from time to time is something we all experience. But for nearly 40 million people in the United States, these worries are much more severe and a constant fixture in their lives. While anxiety disorders may be common, it’s important to know what treatments are available to help manage symptoms.
For many people, prescription medications are an effective way to treat their anxiety. Of the various anti-anxiety medications available, two commonly prescribed options are hydroxyzine (Atarax, Vistaril) and alprazolam (Xanax). While both are FDA-approved to treat anxiety, these two medications are quite different.
Here, we’ll compare how hydroxyzine and alprazolam work to treat anxiety and what to expect should your healthcare provider prescribe one of them for you.
What conditions do hydroxyzine and Xanax treat?
While hydroxyzine and alprazolam are both considered anti-anxiety medications, they are notably different in how they work. Let’s dive into their FDA-approved uses.
Hydroxyzine
Hydroxyzine is an antihistamine, similar to diphenhydramine (Benadryl). There are two versions of this medication — hydroxyzine hydrochloride (Atarax) and hydroxyzine pamoate (Vistaril) — but they share the same uses. Besides treating anxiety, both forms are also FDA-approved for chronic itching and as a sedative to help prepare people for surgery.
While hydroxyzine can be used for multiple anxiety conditions, it is most often prescribed for people with generalized anxiety disorder (GAD).
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It’s important to note that hydroxyzine has not been studied for the long-term (more than 4 months) treatment of anxiety. It’s meant to help relieve symptoms immediately while more preferred anxiety medications — such as buspirone or selective serotonin reuptake inhibitors (SSRIs) — are kicking in.
Xanax
Alprazolam is a benzodiazepine and belongs to the same family as lorazepam (Ativan) and clonazepam (Klonopin). This medication is FDA-approved to treat anxiety disorders (including GAD) and panic disorder.
As with hydroxyzine, alprazolam is intended for short-term use — up to 4 months for anxiety disorders and up to 10 weeks for panic disorder. The American Academy of Family Physicians notes that although benzodiazepines can be helpful in treating initial anxiety, they lack long-term benefits compared to first-choice anxiety medications.
Even when used for short periods of time, alprazolam can be habit-forming and lead to withdrawal symptoms if or when you attempt to stop taking them. This risk is highest if you take more than 4 mg of alprazolam per day. However, withdrawal symptoms may also be possible with long-term use (more than 12 weeks) of lower doses.
What are the differences between hydroxyzine and Xanax?
There are similarities and differences between hydroxyzine and alprazolam. Below, we’ve highlighted some notable features of each medication in a handy table for you.
| Hydroxyzine | Xanax | |
|---|---|---|
| Medication class | Antihistamine | Benzodiazepine |
| Dosage forms | Oral tablet, oral capsule, oral liquid, injectable | Immediate-release (IR) tablet, extended-release (ER) tablet, dissolvable tablet, concentrated oral liquid |
| Available strengths | 10 mg (tablets only), 25 mg, 50 mg, 100 mg (capsules only) | 0.25 mg (IR and dissolvable tablets only), 0.5 mg, 1 mg, 2 mg, 3 mg (ER tablets only) |
| How often is it taken? | Up to 4 times a day as needed | 3 times a day as needed |
| Common side effects | Drowsiness, dry mouth, headache | Drowsiness, lightheadedness, dry mouth |
| Is it habit-forming? | No | Yes, especially at high doses |
| Is it a controlled substance? | No | Yes |
Is hydroxyzine more effective than Xanax?
Research directly comparing these two medications is limited. Currently, only one study is available comparing hydroxyzine and alprazolam. However, it was not looking at people with anxiety disorders. Instead, researchers investigated their effectiveness to help people feel less anxious before surgery.
In this study, participants who took alprazolam experienced less anxiety leading up to their procedure compared to those who took hydroxyzine. The authors were able to determine that alprazolam was more effective than hydroxyzine for pre-surgery anxiety.
While there are no available studies directly comparing these two medications for anxiety disorders, there is a study that compared hydroxyzine to a different benzodiazepine — bromazepam — in people with GAD. Researchers found all participants experienced similar levels of anxiety relief.
This study suggests that hydroxyzine is comparable to bromazepam for treating GAD symptoms. Based on these results, we can say hydroxyzine may be an effective alternative to alprazolam for treating anxiety.
What should I be aware of while taking hydroxyzine or Xanax?
If your healthcare provider decides to prescribe one of these medications for you, there’s some information you should know before getting started.
Hydroxyzine
The suggested starting dose of hydroxyzine for anxiety is 50 mg to 100 mg four times a day. That’s a lot of pills and may be difficult for some people to fit into their regimen. However, your provider’s instructions may be different, so be sure to carefully read your prescription labels. Let your provider know if you’re having trouble fitting in all your doses.
Hydroxyzine kicks in pretty quickly — within 15 to 30 minutes for most people. This means that side effects may also set in quickly. Drowsiness is a common side effect, so don’t drive or perform tasks requiring concentration until you know how this medication affects you.
If you are taking any other medications that cause drowsiness — such as opioids, muscle relaxers, or sleep aids — you should discuss this with your healthcare provider before starting hydroxyzine. This combination can cause severe drowsiness. Your provider may choose to start you on a lower dose of hydroxyzine than what’s typical to help lower your risk of problems from this interaction.
Xanax
The typical starting dose of alprazolam is 0.25 mg to 0.5 mg three times a day. This dose may be lower if you are over 65 years old or have liver problems. Alprazolam is often prescribed with instructions to only take a dose as needed instead of on a fixed schedule. Read your prescription labels closely, and talk to your healthcare provider if you aren’t sure how often to take it.
Alprazolam also works quickly — about an hour after your dose. As with hydroxyzine, side effects will kick in around the same time as symptom relief. Drowsiness and lightheadedness are the most common side effects, so be cautious after taking your dose, especially when you first start taking alprazolam.
Similar to hydroxyzine, alprazolam should not be combined with medications that cause drowsiness. However, alprazolam also interacts with the antidepressant fluoxetine (Prozac). Fluoxetine raises the levels of alprazolam in your body, making side effects from alprazolam more likely.
It’s possible your healthcare provider may prescribe both alprazolam and fluoxetine for you, as they can both treat certain anxiety conditions. If you are prescribed this combination, it’s important to be very cautious when first taking them together. You are more likely to experience drowsiness and impaired concentration when mixing these two.
Does hydroxyzine or Xanax produce fewer side effects?
Hydroxyzine lists fewer potential side effects than alprazolam in their manufacturer package inserts. However, hydroxyzine is linked with a very rare but serious heart rhythm problem that alprazolam is not — QT prolongation. If you have a history of heart rhythm issues (arrhythmias), be sure to discuss this with your healthcare provider before starting hydroxyzine.
The one risk that alprazolam carries that hydroxyzine doesn’t is its ability to be habit-forming. As mentioned above, this risk is highest with high doses of alprazolam. But it may be possible for some people to develop a physical dependence with lower doses as well.
Hydroxyzine may be a better option if you have a history of physical dependence or substance use disorder. But sometimes, your provider may determine that the benefits of alprazolam may still outweigh the risk of dependence for you. It’s best to discuss this with them if it concerns you.
Which medication is better for anxiety?
The answer to this question is unique for everyone. It may take some trial and error to find the best option for treating your anxiety. If neither hydroxyzine nor alprazolam seems to be helping you, let your healthcare provider know. There are still other options available.
The bottom line
Anxiety disorders are one of the most common health conditions in the U.S. Many people find that medications can help relieve their symptoms. Two commonly prescribed anti-anxiety medications are hydroxyzine and alprazolam.
While these two medications work differently in the body, they are both effective at immediately relieving anxiety symptoms. They can be especially useful if you’re waiting for a longer-acting anxiety medication to kick in.
Because hydroxyzine and alprazolam each have unique side effects and drug interactions, it’s best to discuss your medical and medication history with your healthcare provider before starting either. Having an honest conversation about how well they work and what side effects you’re experiencing from them will help your provider find the right choice for you.
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References
Anxiety & Depression Association of America. (2021). What is anxiety and depression?
Franssen, C., et al. (1993). Comparison between alprazolam and hydroxyzine for oral premedication. Canadian Journal of Anesthesia.
Llorca, P. M., et al. (2002). Efficacy and safety of hydroxyzine in the treatment of generalized anxiety disorder: A 3-month double-blind study. The Journal of Clinical Psychiatry.
Locke, A. B., et al. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American Family Physician.
MedlinePlus. (2020). Substance use disorder.
Pfizer. (2020). Vistaril [package insert].
Pharmacia & Upjohn Company LLC. (2021). Xanax [package insert].
RPK Pharmaceuticals Inc. (2020). Hydroxyzine hydrochloride [package insert].
For additional resources or to connect with mental health services in your area, call SAMHSA’s National Helpline at 1-800-662-4357. For immediate assistance, call the National Suicide Prevention Lifeline at 988, or text HOME to 741-741 to reach the Crisis Text Line.
