Butterbur / Feverfew

Summary:
Butterbur and feverfew are herbal remedies that may reduce migraine frequency through anti-inflammatory and vascular effects. Butterbur must be PA-free to avoid liver toxicity.

Biological Plausibility

Butterbur may inhibit leukotriene synthesis and modulate calcium channels. Feverfew may inhibit prostaglandin synthesis and reduce platelet aggregation—both potentially relevant to migraine pathogenesis.

Evidence

RCTs show that butterbur (at least 75 mg BID) can reduce migraine frequency, though safety concerns have limited its use. Feverfew trials show inconsistent results, possibly due to formulation differences.

Effect Size

Butterbur: 2–3 fewer migraine days/month in some studies. Feverfew: smaller or inconsistent effect. About 30–40% response rates reported in responders.

⚠️ Risk

Butterbur may cause liver toxicity unless purified. Feverfew can cause mouth ulcers, withdrawal headaches, or allergic reactions.

Cost

$

Scores

  • Benefit: 2
  • Burden: 3
  • Ratio: 0.67

Clinical Takeaways

  • Only use PA-free butterbur under professional guidance.
  • Effect size comparable to some pharmaceuticals in limited studies.
  • Not recommended as first-line preventive due to safety concerns.

Key References

  • Pittler MH, et al. *Butterbur root extract for preventing migraine: a systematic review.* BMJ. 2004.
  • Diener HC, et al. *Efficacy and safety of feverfew extract in migraine prophylaxis: a randomized, double-blind study.* Cephalalgia. 2005.
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