Key takeaways:
Hydroxyzine (Vistaril, Atarax) and alprazolam (Xanax) are two common anxiety treatments. They work in different ways, but both provide fast relief of anxiety symptoms.
Neither medication is considered a first-choice treatment for anxiety. They are generally prescribed for as-needed relief or while you’re waiting for a long-term treatment to work.
Hydroxyzine and alprazolam can cause drowsiness and dizziness and raise your risk of falls. Alprazolam also has a risk of dependence and misuse. Your prescriber can help you decide which option is best based on your health history and needs.
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Hydroxyzine (Vistaril, Atarax) and alprazolam (Xanax) are two medications commonly prescribed for anxiety. Both are FDA approved to treat anxiety, but these two medications are quite different.
Here, we’ll look at hydroxyzine versus alprazolam to help you understand how these anxiety treatments compare.
1. Hydroxyzine and alprazolam work differently to treat anxiety
Hydroxyzine and alprazolam both treat anxiety. But they belong to different medication classes and work in different ways.
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Hydroxyzine is an antihistamine. It isn’t fully understood how it works for anxiety. But like some other antihistamines, hydroxyzine can make you drowsy. This can help with anxiety-related insomnia. Hydroxyzine also seems to help regulate serotonin levels to reduce anxiety symptoms. This effect is unique to hydroxyzine among the other antihistamines.
Alprazolam is a benzodiazepine. It works by attaching to gamma-aminobutyric acid (GABA) receptors in the body. This in turn has a calming effect on the brain and body.
Hydroxyzine and alprazolam work differently, but they both work quickly to manage anxiety. Both medications typically start working within 30 minutes of your dose.
2. Alprazolam is a controlled substance, but hydroxyzine isn’t
Alprazolam is a controlled substance. So there are more restrictions on how much you can fill at once and how often you can refill your prescription. This is because it carries a risk of dependence and misuse. It also has a risk of overdose, especially if you mix alprazolam with other substances, such as alcohol and opioids. So alprazolam may not be the best choice if you have a history of substance misuse.
Hydroxyzine isn’t a controlled substance. So it doesn’t have the same restrictions and risks as alprazolam. And it may be a safer option for those with a history of substance misuse.
3. Hydroxyzine and alprazolam come in different doses and dosage forms
Hydroxyzine comes in several forms. Hydroxyzine hydrochloride comes as an oral tablet, oral liquid and injectable dosage form. Hydroxyzine pamoate comes as an oral capsule. The two types of hydroxyzine are considered equivalent, and they’re approved for the same health conditions. The typical hydroxyzine dosage for anxiety is 50 mg to 100 mg 4 times a day.
Alprazolam comes as an immediate-release oral tablet, liquid, and dissolving tablet. It’s also available as an extended-release (XR) tablet. The typical alprazolam dosage for anxiety starts at 0.25 mg to 0.5 mg 3 times a day (0.5 mg to 1 mg once daily for the XR version).
Both medications offer flexibility if you take them only as needed when anxiety symptoms occur. They also both offer options for those who have trouble swallowing tablets. But alprazolam XR may be a preferred option for those who prefer taking medication once daily for long-lasting relief.
4. Hydroxyzine and alprazolam have different side effects to consider
Hydroxyzine and alprazolam have some similar side effects, including:
Drowsiness
Dizziness
Constipation
Increased risk of falls
Hydroxyzine can also cause trouble peeing, blurry vision, and dry mouth. Rare but serious hydroxyzine side effects include confusion, abnormal heart rhythms, and hallucinations. These serious side effects are more likely if you take higher doses than recommended.
Additional alprazolam side effects include decreased sex drive, memory problems, and weight changes. Serious alprazolam side effects and risks include worsening depression, excessive sedation, and substance misuse.
Neither medication is recommended for older adults because they can raise the risk of confusion and falls. The other medications you take can also raise the risk of certain side effects. Your prescriber can review the side effects of each option for you. Then you can determine if one is a better fit based on your personal history.
5. Hydroxyzine and alprazolam are not meant for long-term anxiety relief
Hydroxyzine and alprazolam are effective options for short-term anxiety relief. They’re typically prescribed for fast relief when taken as needed for anxiety symptoms. You can also take them while you’re waiting for a long-term anxiety treatment to start working.
But neither medication is a first-choice anxiety treatment. And neither is recommended for long-term anxiety relief. If you experience frequent or ongoing anxiety symptoms, ask your prescriber about a preferred treatment, such as a selective serotonin reuptake inhibitor (SSRI).
Choosing between hydroxyzine and alprazolam for anxiety
There’s limited research comparing hydroxyzine and alprazolam directly for anxiety. In general, the medications are considered similarly effective. But they have some limitations to consider.
Hydroxyzine has mostly been studied for general anxiety disorder. So it’s unclear if it’s as effective as alprazolam and other benzodiazepines for panic disorder or acute anxiety symptoms.
But hydroxyzine doesn’t carry the same risks of misuse and dependence as alprazolam. So it may be a safer option for people with a history or concern about substance misuse.
The chart below summarizes the key differences between hydroxyzine and alprazolam for anxiety. Your healthcare team can help you review the risks and benefits of both medications to find the best fit for your needs.
| Hydroxyzine | Alprazolam | |
|---|---|---|
| Medication class | Antihistamine | Benzodiazepine |
| Dosage form |
|
|
| Typical dosage |
|
|
| Side effects |
|
|
| Is it a controlled substance (habit forming)? | No | Yes |
Frequently asked questions
Xanax isn’t considered a first-choice option for treating anxiety. Other medications that are safer and more effective for ongoing anxiety symptoms include:
SSRIs, such as paroxetine (Paxil)
Serotonin norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta)
Buspirone (Buspar)
Hydroxyzine and Benadryl (diphenhydramine) are both antihistamines, but they aren’t the same. Both medications are effective treatment options for allergy symptoms. But Benadryl is available over the counter, while hydroxyzine is prescription only. Also, hydroxyzine is FDA approved to treat anxiety, but Benadryl isn’t.
Benzodiazepines are sometimes prescribed for pain associated with muscle spasms. But they aren’t considered a pain medication. And they’re typically not a first-choice option for most pain-related conditions. You shouldn’t take Xanax for pain unless directed to by a healthcare professional.
Xanax isn’t considered a first-choice option for treating anxiety. Other medications that are safer and more effective for ongoing anxiety symptoms include:
SSRIs, such as paroxetine (Paxil)
Serotonin norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta)
Buspirone (Buspar)
Hydroxyzine and Benadryl (diphenhydramine) are both antihistamines, but they aren’t the same. Both medications are effective treatment options for allergy symptoms. But Benadryl is available over the counter, while hydroxyzine is prescription only. Also, hydroxyzine is FDA approved to treat anxiety, but Benadryl isn’t.
Benzodiazepines are sometimes prescribed for pain associated with muscle spasms. But they aren’t considered a pain medication. And they’re typically not a first-choice option for most pain-related conditions. You shouldn’t take Xanax for pain unless directed to by a healthcare professional.
The bottom line
Hydroxyzine (Vistaril, Atarax) and alprazolam (Xanax) are both commonly prescribed for anxiety. These two medications work differently in the body. But they’re both considered effective options for fast relief of anxiety symptoms. They’re also often prescribed while you’re waiting for a long-term anxiety medication to kick in.
Neither hydroxyzine nor alprazolam is considered a first-choice option for treating anxiety. And they’re considered safe only for short-term use. Both medications can cause drowsiness and dizziness and increase your risk of falls. Alprazolam also carries an additional risk of dependence and misuse. Your prescriber can help you weigh the risks and benefits of hydroxyzine versus alprazolam based on your personal history and needs.
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References
Krieger, A. (2025). Benzos (as) needed: Research into as-needed and intermittent benzodiazepines for anxiety is required for comprehensive best prescribing practices. Frontiers in Psychiatry.
