What medicine is given for anxiety before surgery? An Overview of Pre-Operative Sedation

October 10, 2025 •

5 min read

Studies show that as many as 80% of patients experience some level of anxiety before a procedure, a phenomenon known as pre-operative anxiety. To address this, healthcare teams often administer medication designed to promote relaxation and calmness. Knowing what medicine is given for anxiety before surgery can help patients feel more informed and prepared for their procedure.

Quick Summary

Anesthesiologists commonly prescribe sedative-hypnotic medications, such as benzodiazepines like midazolam, to manage patient anxiety before surgery. Alternative options include melatonin, antihistamines, and alpha-2 agonists, with the choice depending on individual health, age, and procedure type.

Key Points

Benzodiazepines are common pre-op drugs: Medications like midazolam, lorazepam, and diazepam are frequently used for pre-surgical anxiety due to their rapid onset and calming effects.
Midazolam can cause amnesia: Midazolam is particularly notable for its ability to induce anterograde amnesia, helping patients not remember stressful parts of the procedure.
Non-benzodiazepine alternatives exist: Options like melatonin, sedating antihistamines (hydroxyzine), and alpha-2 agonists are available, offering alternatives with different side effect profiles.
Medication is administered in various ways: Depending on the patient and procedure, drugs can be given orally, intravenously, or intranasally, especially for children.
Risks and benefits are weighed individually: Anesthesiologists assess each patient to balance the benefits of anxiety reduction against risks like over-sedation or cognitive issues, especially in older adults.
Non-pharmacological methods are also effective: Techniques like patient education, music therapy, and relaxation exercises can significantly help manage pre-operative anxiety, often alongside medication.

Understanding Pre-Operative Anxiety and Medicated Anxiolysis

Pre-operative anxiety is a natural response to the stress of an impending medical procedure. It is caused by various factors, including fear of the unknown, concern about surgical outcomes, and the anticipation of pain. Left unmanaged, excessive anxiety can lead to undesirable effects, such as an increased heart rate, higher blood pressure, and a more difficult post-operative recovery. To mitigate these risks, anesthesiologists often provide medication, or premedication, to calm patients and prepare them for anesthesia and surgery. This pharmacological intervention, also known as anxiolysis, is a critical step in ensuring patient comfort and improving surgical outcomes.

The Primary Class: Benzodiazepines

For decades, benzodiazepines have been the cornerstone of pharmacological management for pre-operative anxiety due to their rapid action and effectiveness. These sedative-hypnotic medications work by enhancing the effect of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits activity in the central nervous system. This results in a calming, anxiety-reducing effect and, in some cases, amnesia, which helps patients forget the more stressful aspects of the surgical procedure.

Common Benzodiazepines for Pre-Surgery Use

Midazolam (Versed®): This is one of the most commonly used benzodiazepines in surgical settings. It is often administered intravenously (IV) in the operating room or as a syrup or nasal spray for children before they are taken from their parents. Midazolam has a rapid onset and a short duration, making it ideal for immediate anxiolysis and providing a period of amnesia.
Lorazepam (Ativan®): An intermediate-acting benzodiazepine, lorazepam can be given orally or via injection. It is known for its ability to reduce anxiety and promote relaxation before surgery, and its effects can last for several hours.
Diazepam (Valium®): As a longer-acting benzodiazepine, diazepam can be prescribed to be taken orally the night before or the morning of surgery for particularly anxious adults. It provides a lasting calming effect but can also cause drowsiness.

Non-Benzodiazepine Alternatives

While benzodiazepines are effective, they are not suitable for all patients due to potential side effects like over-sedation or increased risk of postoperative delirium in older patients. This has led to the increased use of alternative medications.

Alternatives for Adults and Children

Melatonin: A natural hormone that regulates the sleep-wake cycle, melatonin can effectively reduce pre-operative anxiety with fewer side effects than benzodiazepines, such as cognitive impairment. It is available orally and can provide a calming, sedative effect.
Antihistamines: Certain sedating antihistamines, such as hydroxyzine, can be used to control anxiety and promote sleep before surgery. It is available in oral forms and works within 30–60 minutes, though it can cause notable sedation and dry mouth.
Alpha-2 Agonists: Drugs like dexmedetomidine (Precedex™) and clonidine can offer anxiolytic and sedative effects. Dexmedetomidine, in particular, can be administered intranasally in children, offering a potent anxiety-reducing effect.
Gabapentinoids: Medications like pregabalin (Lyrica) are anticonvulsants that also possess anxiolytic properties. Some studies have shown it can reduce anxiety and lower postoperative opioid requirements.

How Medications Are Administered

The method of administering pre-operative medication depends on the specific drug, the patient's age, and the urgency of the procedure. Common routes include:

Oral (by mouth): Many medications, including oral benzodiazepines, melatonin, and antihistamines, are given as a pill or liquid to be swallowed before arriving at the hospital or in the pre-operative waiting area. This is a common and non-invasive approach for adult and pediatric patients.
Intravenous (IV): In hospital settings, especially for more immediate effects or in children who are not cooperative with oral medication, a medication like midazolam can be administered directly into a vein.
Intranasal (IN): For young children, intranasal administration using a nasal atomizer is a quick and effective way to deliver medications like midazolam and dexmedetomidine without the need for an IV line.

Weighing the Risks and Benefits

The decision to use pre-operative anxiety medication involves balancing the benefits of reduced patient stress against the potential risks. While alleviating anxiety can improve the patient experience and potentially lower the risk of complications like prolonged hospital stays or increased pain sensitivity, medications also carry side effects. Side effects can include drowsiness, dizziness, confusion, headaches, and—in more serious cases, particularly with benzodiazepines—respiratory depression. Special precautions must be taken for certain populations, such as the elderly, who are at higher risk for side effects like delirium. The anesthesiologist will consider the patient's full medical history and individual circumstances before determining the best approach.

A Comparison of Common Pre-Operative Anxiolytics


Medication Class	Example(s)	Mechanism of Action	Typical Administration	Common Use Case	Potential Side Effects
Benzodiazepines	Midazolam, Lorazepam	Enhances GABA's inhibitory effect in CNS.	Oral, IV, Intranasal	General anxiolysis, amnesia.	Drowsiness, confusion, respiratory depression.
Antihistamines	Hydroxyzine	Blocks histamine, causing sedation.	Oral	Patients needing mild sedation, especially if benzodiazepines are contraindicated.	Drowsiness, dry mouth.
Melatonin	Melatonin	Regulates sleep-wake cycle, has sedative properties.	Oral	Alternative for anxiety with less impact on cognition, especially in elderly.	Dizziness, headache.
Alpha-2 Agonists	Dexmedetomidine	Activates alpha-2 adrenergic receptors.	Intranasal (children), IV	Pediatric sedation, providing anxiolysis and analgesia.	Bradycardia, hypotension.

The Role of Non-Pharmacological Strategies

Medication is not the only way to combat pre-operative anxiety. A multi-pronged approach that incorporates non-pharmacological methods is often most effective. These strategies can be used in conjunction with or sometimes as an alternative to medication, depending on the severity of the anxiety. They are particularly valuable for patients who are hesitant to take medication or for whom certain drugs are contraindicated.

Examples of Non-Pharmacological Methods

Patient Education: Providing clear and comprehensive information about the procedure, anesthesia, and recovery process can significantly reduce a patient's fear of the unknown. Studies show that effective communication can alleviate a great deal of anxiety.
Relaxation Techniques: Techniques such as deep breathing, meditation, and guided imagery can help patients calm their nervous system. Learning these simple techniques can give a patient a sense of control over their anxiety.
Music Therapy: Listening to calming or preferred music before surgery has been shown to reduce anxiety levels. Many hospitals now facilitate this with headphones in the pre-operative holding area.
Virtual Reality (VR): Immersive VR experiences can serve as a distraction technique, effectively reducing anxiety levels by diverting the patient's attention from their fears.

Conclusion

Pre-operative anxiety is a common and treatable issue that affects a majority of patients. A variety of medications, most notably benzodiazepines like midazolam, are available to provide rapid and effective relief. However, non-benzodiazepine alternatives such as melatonin, antihistamines, and alpha-2 agonists offer effective options with potentially different side effect profiles. The choice of which medication to use is a personalized one, made by the anesthesiologist based on the patient's medical history, age, and specific surgical needs. Open communication with the healthcare team about your fears and preferences is the best way to ensure that your pre-operative anxiety is managed effectively, leading to a smoother and more comfortable surgical experience. Utilizing a combination of medication and non-pharmacological strategies can help patients achieve the best possible outcome. For authoritative information, it is best to consult with your physician or refer to resources from institutions like the National Institutes of Health.

Frequently Asked Questions

Midazolam (Versed®), a benzodiazepine, is one of the most commonly used medications given before surgery to reduce anxiety and induce drowsiness. It is often administered intravenously for a fast-acting effect.

No, medication is not always necessary. Many patients can manage their pre-operative anxiety with non-pharmacological techniques like deep breathing or music. The need for medication is evaluated by the anesthesiologist based on the individual patient's anxiety level and medical history.

Alternatives to benzodiazepines include melatonin, which helps regulate sleep; antihistamines like hydroxyzine, which have sedative effects; and alpha-2 agonists like dexmedetomidine, which provide sedation and pain relief.

Use of anti-anxiety medication in elderly patients requires careful consideration. Benzodiazepines may increase the risk of side effects such as postoperative delirium. Anesthesiologists may opt for lower doses or alternatives like melatonin in older adults.

Common medications for children include oral midazolam or intranasal dexmedetomidine. The route of administration is chosen to be as non-invasive as possible and appropriate for the child's age and comfort level.

No. Patients are typically instructed not to eat or drink anything after a certain time before surgery. It is crucial to follow all pre-operative instructions from your healthcare team regarding food, drink, and medication to avoid complications.

Some medications, particularly benzodiazepines like midazolam, can cause anterograde amnesia, meaning you may not remember events that occurred after the medication was given. This effect is often desirable to help minimize the memory of a stressful procedure.