If you’ve heard about butterbur for migraine prevention you’ve likely heard how helpful it can be while also being advised to be leery of it due to safety concerns. I was once advised to take butterbur, but that advice was shortly followed up with a warning not take the medicinal herb.
This quick pivot in opinion made me wonder what had changed and if the caution was warranted. The suggestion and then retraction came from my well-known and respected headache specialist at Jefferson Headache Center in Philadelphia. I had been impressed with their expertise and was curious about the reversal.
Is butterbur safe and effective for migraine? Is there updated information? Let’s explore both efficacy and safety for this natural treatment.
** While Migraine Strong writes about the latest in migraine treatments, this is not medical advice. We are patient educators and all information you read should be discussed with your doctor.
Question 1- What is this substance with the funny name, butterbur?
Butterbur is a plant that has been used for centuries for medicinal purposes. It gets its name as it has large leaves that were useful in wrapping butter and allowing it to keep cool and neatly packaged in the ice box.
Both butterbur and feverfew are in the Asteraceae family and known to herbalists. In terms of migraine supplements, feverfew is considered one of the “Big 5” to consider as it has been shown to be potentially helpful while being safe.
Several years ago, butterbur was also considered even more helpful for migraine than feverfew. Let’s take a look at the evidence that had my neurologist and many other headache specialists excited about the potential to help.
Question 2- What is the science supporting butterbur for migraine?
The studies of the therapeutic value of butterbur focus on the value of the “active ingredients” of the plant, petasins. All of the studies used Petadolox ®, an extract made only from the root of the butterbur plant.
Most of the studies were done in the early 2000s and included both adults and children. All studies used the formulation made in Germany by Weber & Weber.
The main butterbur studies on migraine prevention
The largest study on butterbur for migraine was conducted with 245 adults over a 4 month period of time. The researchers tested 2 different doses, 75 mg Petadolex ® twice per day, 50mg Petadolox ® twice per day or a placebo twice per day. Each participant reported having at least 3 to 6 migraine episodes per month as their baseline level of migraine.
The results were very encouraging. Butterbur reduced migraine episodes by half in 68% in the group taking 75 mg twice per day. Additionally, the preventive nature of butterbur kicked in as soon as 1 month for some people. The group taking 50 mg twice per day did not see a statistically significant improvement over the placebo group.
The reported side effects were minimal with burping as the main complaint. So, for emphasis, this herbal remedy worked as well or better than some prescribed, costly medications and had no major side effects.
In another placebo-controlled study of 60 adults, using 100 mg of the Petadolex supplement, it was also shown that butterbur helped migraine compared to the placebo group. Over half of the participants taking butterbur benefited and had minimal side effects.
A promising study in pediatrics
In 2005, children 6-17 were given between 50 and 150 mg of the Petadolex supplement per day to test the effectiveness of butterbur for migraine prevention in kids. 77% of the children saw their attack frequency cut in half. 91% of the participants said they felt at least some improvement. Nobody stopped the study early due to side effects.
Just like the adult study, burping was the only significant side effect.
Question 3- How does the active ingredient in butterbur help migraine?
Petasins are a natural chemical compounds found in Butterbur. Petasins are thought to potentially help in a few ways. Most notable, petasins may help reduce inflammation and decrease some inflammatory mediators. In migraine, inflammation, especially neuroinflammation is thought to be part of the migraine process.
The newer class of migraine medications, CGRP antagonists have been game-changers for many with both episodic and chronic migraine. Calcitonin gene-related peptide (CGRP) is a protein that is involved in generating head pain and other symptoms of migraine. During an attack, levels of CGRP increase. Some research suggests that petasins may be involved in interfering with the rise in CGRP.
Perhaps the butterbur helps migraine by being a CGRP foe like some migraine preventive medications.
Question 4- What are the safety concerns about recommending butterbur?
The extract of butterbur contains helpful petasins but harmful pyrrolizidine alkaloids (PAs). PAs are toxic to the liver and may possibly lead to liver cancer. There is no controversy about PAs. It is clear that they must be removed during processing so they are not in supplements.
The safety concerns about taking butterbur for migraine are two-fold. The first issue centers around confidence in the poorly regulated supplement industry and whether or not the manufacturers can be trusted to properly remove PAs from their butterbur product. Because butterbur can be expensive, those considering it may choose a cheaper, low quality brand that may not have effective safety standards.
The second concern is that some people looking for migraine help may not consult their doctor. Some physicians may wish to monitor certain labs to make sure there is no adverse impact on the liver.
Which Butterbur was used in the migraine studies?
In all of the butterbur studies, the Petadolex brand supplement was used. This specific product is manufactured in Germany by Weber & Weber and distributed in the US by Linpharma. This company has held a patent for many years for making the butterbur PA-free. No other brand of butterbur has been researched for migraine prevention.
The regulatory issue
According to this published paper about the safety of butterbur for migraine prevention, this manufacturer ran afoul with the German regulatory agency for changing the extraction processing of butterbur from methylene chloride to CO2. Chemical analysis showed that the extraction processes provided comparable products, but the German regulatory agency rejected their authorization in 2008 as they said it was not the same product anymore.
To get authorized, they’d have to go through the expensive approval process all over again.
It’s important to note that the above studies showing effectiveness and safety of butterbur for migraine were done with the CO2 extraction method.
The US and Canada
In 2012, Health Canada approved Petadolex ® butterbur for migraine prevention. In the US, the Petadolex supplement has been available as a dietary supplement since 1998.
The supplement industry in the US is poorly regulated. We get many supplement options to choose from but the quality is mixed. When tested by labs, it’s not unusual for the actual ingredients of the product to not match what the label says. This is why it’s important to only buy from manufacturers that have good quality standards and use independent labs to check for quality.
An update in 2020
At the 2020 annual Winter Headache Conference, Dr. Jurgen Borlak discussed recent conculsions about the safety of the Petadolex for migraine prevention. The medical doctor’s opinion carries some weight as he is also a pharmacologist and world-renowned toxicologist.
According to Dr. Borlak, “no adverse events have been reported in the U.S. or Canada despite 1.3 million patient months of Petadolex.
In his published review of the safety of butterbur when used for migraine prevention, Dr. Borlak recommended monitoring liver enzymes as well as avoiding the potential remedy for people with certain medical conditions.
Some neurologists have renewed confidence while others remain reluctant to recommend butterbur, in general. However, they may consider working individually with an interested patient.
Question 5- Who should not consider butterbur for migraine?
According the the Petadolex supplement site:
If you are pregnant, planning to conceive or have liver disease, consult with your doctor before taking Petadolex® or any other supplement.
Do not use Petadolex if you have any liver disease or condition that impairs liver function, a history of alcohol abuse, or are currently consuming St. John’s Wort. Consult your physician before taking Petadolex if you are a long-time user of high doses of OTC pain relief medications such as acetaminophen or if you are a long term user of non-steroidal anti-inflammatory drugs like diclofenac.
While the site did not mention using butterbur while breastfeeding, talking to your baby’s pediatrician would be wise prior to taking the supplement.
Some final words
At Migraine Strong we strive to give you the most up-to-date information with supportive evidence and real world experience. We take this seriously. This is not medical advice nor a substitute for medical advice. Here are our suggestions:
- Discuss butterbur for migraine with your doctor. We all know that many of today’s migraine preventive medications can be effective, but they may have unacceptable side effects or you may not have access due to availability or expense. Butterbur may be a good option.
- If your doctor is not well-versed in the topic, bring this article to their attention.
- Assuming your doctor approves of you trying butterbur for migraine prevention, make sure you are using the product used in the studies, the Petadolex supplement. Personally, I would only use the product made in Germany by Weber & Weber and I would insist on monitoring my liver enzymes. There are less expensive options but resist the urge to find a bargain brand. Additionally, discuss the right dosage. The studies found 75 mg twice per day most effective for adults.