What is Butterbur?
Butterbur (Petasites hybridus) is a perennial shrub native to Europe, Asia, and parts of North America. It grows in wet, marshy areas near streams and rivers. The name "butterbur" comes from the traditional practice of using its large leaves to wrap butter during warm weather to prevent melting.
Active Components: The herb contains petasins (sesquiterpene compounds), which are responsible for its therapeutic effects. Petasins have anti-inflammatory, anti-spasmodic, and vasodilatory properties.
Critical Safety Note: Butterbur naturally contains pyrrolizidine alkaloids (PAs), which are toxic compounds that can cause severe liver damage, lung toxicity, and cancer. ONLY use products certified and labeled as PA-free.
Primary Functions & Benefits
Proven Therapeutic Uses:
Migraine Prevention: Reduces frequency and severity of migraine attacks
Allergic Rhinitis (Hay Fever): Alleviates seasonal allergy symptoms
Anti-inflammatory Effects: Reduces inflammation throughout the body
Smooth Muscle Relaxation: Relieves spasms in blood vessels and airways
Mechanism of Action:
Inhibits leukotriene and histamine activity (natural antihistamine effect)
Blocks calcium channels in smooth muscle, causing vasodilation
Inhibits COX-2 and prostaglandin E2 (anti-inflammatory pathways)
Reduces reactive oxygen species (antioxidant effects)
Health Benefits Supported by Research:
Migraine Prevention (Strongest Evidence):
Reduces migraine frequency by 40-60% in clinical trials
Decreases intensity and duration of attacks
Effective in both adults and children
Previously received Level A recommendation from American Academy of Neurology (withdrawn in 2015 due to safety concerns)
Allergic Rhinitis:
Comparable effectiveness to antihistamines (cetirizine/Zyrtec, fexofenadine/Allegra)
Reduces nasal congestion, runny nose, sneezing, and itchy eyes
Causes less drowsiness than traditional antihistamines
Works for seasonal (hay fever) and perennial allergies
Asthma (Limited Evidence):
May improve symptoms in some patients
Reduces bronchial constriction
Complementary to inhaled corticosteroids
Other Potential Uses (Insufficient Evidence):
Tension headaches
Stomach ulcers
Anxiety and stress
Skin conditions (eczema)
Cognitive protection (preliminary research)
Recommended Dosages
Adults:
For Migraine Prevention:
Standard dose: 50-75 mg twice daily (total 100-150 mg/day)
Alternative: 50 mg three times daily
Treatment duration: Minimum 12-16 weeks for full effect
Most studies used Petadolex brand (specific extract)
For Allergic Rhinitis:
Standard dose: 50 mg two to three times daily (total 100-150 mg/day)
Specific extract Ze 339 (Tesalin) studied most extensively
Can be taken seasonally or year-round for perennial allergies
Children:
Migraine Prevention:
Ages 6-8: Not recommended (insufficient safety data)
Ages 8-9: 50-75 mg daily in divided doses
Ages 10-17: 100-150 mg daily in divided doses
Maximum duration: 4 months studied
Dosing Guidelines:
Always take with meals to improve absorption and reduce stomach upset
Divide total daily dose into 2-3 administrations
Start with lower doses and gradually increase if needed
Use only PA-free, standardized extracts (15% petasins typical)
Food Sources
Butterbur is not consumed as a food. While the plant has been used traditionally in some cultures (Japanese butterbur/fuki is consumed in Japan), the therapeutic extracts come from:
Root/rhizome (most common for migraine)
Leaves (used for allergic rhinitis)
Processing removes toxic PAs and concentrates active petasins
Important: Do NOT harvest or consume wild butterbur due to high PA content.
Timing & Administration
Best Time to Take:
With meals - always take with food
Morning and evening for twice-daily dosing
Morning, midday, and evening for three-times-daily dosing
No specific advantage to morning vs. evening
Duration of Use:
Short-term: Up to 16 weeks studied and considered possibly safe
Long-term safety: Not established; avoid prolonged continuous use
Cyclic approach: Consider taking seasonally for allergies or during migraine-prone periods
Absorption Factors:
Food enhances absorption and reduces GI upset
Fat content in meals may improve absorption of petasins
Effects build gradually over weeks (not immediate relief)
Synergistic Supplements
May Enhance Benefits:
Magnesium: Complementary for migraine prevention
Riboflavin (Vitamin B2): Another evidence-based migraine preventive
Coenzyme Q10: Works synergistically for migraines
Feverfew: Another herbal migraine preventive (use cautiously together)
For Allergies:
Quercetin: Natural antihistamine
Vitamin C: Supports immune function and reduces histamine
Probiotics: May reduce allergic response
Stinging nettle: Complementary allergy herb
General Support:
Milk thistle: May protect liver (theoretical benefit given PA concerns)
N-acetylcysteine (NAC): Antioxidant support
Note: There is no strong clinical evidence for specific combinations with butterbur, but these supplements address similar conditions.
Drug Interactions & What NOT to Take
Moderate Interactions - Use Caution:
Cytochrome P450 3A4 Inducers:
Carbamazepine (Tegretol)
Phenobarbital
Phenytoin (Dilantin)
Rifampin
Rifabutin (Mycobutin)
St. John's Wort
Effect: May increase production of toxic metabolites
Anticoagulants/Antiplatelets:
Warfarin
Aspirin
Clopidogrel (Plavix)
NSAIDs
Effect: Theoretical increased bleeding risk (not well-documented)
Anticholinergic Medications:
Contraindicated - avoid combining
May have opposing effects
Calcium Channel Blockers:
Amlodipine, diltiazem, verapamil
Effect: Additive blood pressure lowering effects (theoretical)
Medications That May Affect Liver Enzymes:
Use caution with any hepatotoxic medications
Monitor liver function if combining
Avoid With:
Other herbal supplements processed through CYP3A4
Multiple supplements containing similar compounds
Isotretinoin or other hepatotoxic drugs
Who Should Take Butterbur
Ideal Candidates:
Adults with frequent migraines (4+ per month) seeking natural prevention
People with seasonal allergic rhinitis resistant to or intolerant of antihistamines
Individuals preferring herbal approaches to prevention
Those who experience drowsiness from traditional antihistamines
Patients with mild-to-moderate asthma as adjunctive therapy
People with chronic tension headaches (limited evidence)
Best Results Seen In:
Migraine sufferers willing to take daily preventive for 12+ weeks
Those with predictable seasonal allergies
Patients using PA-free, standardized, quality-tested products
Individuals under medical supervision with liver function monitoring
Who Should AVOID Butterbur
Absolute Contraindications:
Pregnant women: Risk of birth defects and liver damage
Breastfeeding mothers: May harm infant
Children under 6 years: Safety not established
Liver disease or dysfunction: Risk of hepatotoxicity
Allergy to Asteraceae family: Ragweed, chrysanthemums, marigolds, daisies
Anyone taking anticholinergic medications
Use Extreme Caution or Avoid:
Kidney disease
History of bleeding disorders
Scheduled for surgery (stop 2 weeks prior)
Taking multiple liver-metabolized medications
Heavy alcohol consumption
History of liver problems or abnormal liver enzymes
Not Recommended:
Long-term continuous use (>16 weeks)
Anyone unable to verify PA-free certification
Children 6-8 years old (insufficient data)
Safety Profile & Side Effects
Common Side Effects (Generally Mild):
Belching and flatulence (most common)
Upset stomach, dyspepsia
Nausea
Headache (ironic for migraine treatment)
Diarrhea
Itchy eyes
Drowsiness and fatigue (less than traditional antihistamines)
Asthma symptoms (rare)
Frequency: Most side effects occur in <5% of users and are mild.
Serious Side Effects (Rare but Critical):
Hepatotoxicity (Liver Damage):
Cholestatic hepatitis (estimated 1:175,000)
Elevated liver enzymes (AST, ALT, ALP)
Jaundice
Dark urine
Severe fatigue
Two liver transplants reported (unclear if from PAs or butterbur itself)
Pyrrolizidine Alkaloid Toxicity (If PAs Present):
Hepatic veno-occlusive disease
Liver cirrhosis and failure
Pulmonary toxicity
Carcinogenesis (cancer-causing)
Thrombosis
Allergic Reactions:
Skin rash, hives
Difficulty breathing
Anaphylaxis (extremely rare)
Duration of Safety:
Up to 16 weeks: Possibly safe (PA-free products)
Beyond 16 weeks: Unknown; not recommended
Long-term use: Not studied; avoid
Deficiency Symptoms
Not Applicable: Butterbur is not an essential nutrient. There is no such thing as butterbur deficiency. It is an herbal supplement used for specific therapeutic purposes, not a vitamin or mineral required for normal body function.
Toxicity Symptoms
From Pyrrolizidine Alkaloids (PA-Containing Products):
Acute Toxicity:
Severe abdominal pain
Nausea and vomiting
Hepatomegaly (enlarged liver)
Ascites (fluid in abdomen)
Jaundice
Chronic Toxicity:
Progressive liver damage (cirrhosis)
Hepatic veno-occlusive disease
Portal hypertension
Liver failure requiring transplant
Pulmonary arterial hypertension
Increased cancer risk
Overdose of PA-Free Butterbur:
No specific antidote exists
Discontinue use immediately
Supportive care for symptoms
Monitor liver function
Signs Requiring Immediate Medical Attention:
Yellowing of skin or eyes (jaundice)
Dark urine or pale stools
Severe abdominal pain
Unexplained fatigue or weakness
Bleeding or bruising easily
Confusion or altered mental status
Special Considerations
Liver Function Monitoring:
Critical: Have liver function tests (AST, ALT, ALP, bilirubin) checked before starting
Recheck at 4-8 weeks, then periodically
Stop immediately if enzymes become elevated
Product Quality Issues:
Major concern: 2012 study found 7 of 21 products contained PAs despite claims
Look for third-party testing (USP, ConsumerLab, NSF certification)
Use reputable brands: Petadolex, Tesalin (Ze 339) most studied
Be skeptical of "PA-free" claims without certification
Regulatory Status:
FDA: Not approved; sold as dietary supplement (not regulated like drugs)
Germany: Restricted to 1 mcg PA/day for <6 weeks or 0.1 mcg/day long-term
UK: Products voluntarily withdrawn due to hepatotoxicity reports
Canada: Previously recommended by guidelines, now cautious due to safety
Guidelines Reversal:
2012: American Academy of Neurology gave Level A recommendation for migraine
2015: Recommendation withdrawn due to safety concerns and variable product quality
Current stance: Benefits do not clearly outweigh risks for most patients
Pregnancy & Lactation:
Pregnancy Category: Not established; presumed unsafe
Risk: Teratogenic (birth defects) and hepatotoxic potential
Breastfeeding: Unknown if excreted in milk; avoid due to infant risk
Age-Related Factors:
Children <6: Not studied; do not use
Children 6-8: Insufficient data; generally avoid
Children 9-17: Limited data; use only under medical supervision
Elderly: No specific contraindications but increased medication interactions
Duration of Treatment:
Migraines: Expect 4-12 weeks for noticeable reduction in frequency
Allergies: May work within days but optimal effect takes 1-2 weeks
Maximum studied duration: 16 weeks
Recommendation: Use shortest effective duration; consider breaks
Comparison to Conventional Treatments
vs. Antihistamines (for Allergies):
Effectiveness: Comparable to cetirizine and fexofenadine
Advantages: Less drowsiness, natural option
Disadvantages: Safety concerns, less well-studied
vs. Migraine Medications:
Effectiveness: Moderate (50-60% reduction vs. 40% with placebo)
Advantages: Fewer side effects than some preventives (beta-blockers, topiramate)
Disadvantages: Safety concerns, slower onset, requires daily use
Current Medical Consensus
Bottom Line: While butterbur showed promise for migraine prevention and allergic rhinitis, serious safety concerns have limited its use:
Efficacy: Moderate evidence for benefits in clinical trials
Safety: Significant concerns about liver toxicity and product quality
Quality Control: Many products contain PAs despite "PA-free" labels
Medical Guidance: Most professional organizations now recommend against use or advise extreme caution
Alternatives Available: Safer options exist for both migraines and allergies
Summary & Key Takeaways
Butterbur is an herbal extract with clinically demonstrated benefits for migraine prevention and allergic rhinitis, but significant safety concerns limit its use. The herb contains toxic pyrrolizidine alkaloids that must be removed during processing, but product quality is inconsistent and liver damage has been reported even with supposedly PA-free products.
If You Choose to Use Butterbur:
Only use certified PA-free products from reputable manufacturers with third-party testing
Get baseline liver function tests before starting and monitor regularly
Use the lowest effective dose for the shortest duration needed
Do not exceed 16 weeks of continuous use
Take with meals to minimize stomach upset and improve absorption
Avoid if pregnant, breastfeeding, or have liver disease
Stop immediately if you develop signs of liver problems
Inform all healthcare providers you're taking butterbur
Consider safer alternatives first, especially for long-term use
Safer Alternatives to Consider:
For Migraines: Magnesium, riboflavin, CoQ10, feverfew, prescription preventives
For Allergies: Standard antihistamines, nasal corticosteroids, immunotherapy, quercetin
Medical advice: Given the safety concerns and availability of proven alternatives, consult with a healthcare provider before using butterbur. The potential benefits may not outweigh the risks for most people.