Butterbur for Migraine Prophylaxis
Use of butterbur is more controversial than riboflavin. A randomized, parallel-group study involving over 200 patients found that the group given butterbur had a response rate of 45%, three times better than the response found with placebo. Another randomized controlled trial, this one involving only 33 patients, examined efficacy of butterbur as prophylaxis. Similarly, this study concluded that butterbur reduced the frequency of migraines by 48% in the experimental group, almost double the reduction found in the control group.
A multicenter, open-label trial in just over 100 kids aged 6-17 years found similar results. About three quarters of participants experienced at least a 50% reduction in headache frequency. No serious adverse events were reported.
The most common side effect, reported by 7%, was eructation.
That does not mean that these products are risk-free. Some butterbur products may contain pyrrolizidine alkaloids (PAs) — a major safety concern. According to the National Center for Complementary and Integrative Health (NCCIH), PAs can damage the liver and lungs, and possibly cause thrombosis and cancer. Patients should be counseled to look for products that are PA-free. One caveat, however: The NCCIH notes that those products may not, in fact, really be PA-free. Butterbur should not be taken by pregnant or breast-feeding women.
The 2012 American Headache Society and the American Academy of Neurology guideline stated that the product had level A evidence for use and was a valid option for patients with migraine. However, the recommendation was questioned owing to reported safety concerns and has now been retracted.
Vitamin E for Menstrual Migraine
Although the woman in this case did not report that her headaches were triggered by menstruation, menstrual migraine is another common variant often seen in primary care. Menstrual migraine is associated with increased prostaglandin levels in the endometrium. Does that mean there is a role for vitamin E, an antiprostaglandin, in prophylaxis?
A placebo-controlled, double-blind, crossover trial involving 72 women with headache associated with menses evaluated the efficacy of vitamin E. The women received placebo for 5 days around menses for two cycles. After a washout period, they were then given vitamin E, 400 units daily, for an additional two cycles. During the vitamin E phase, the women reported a decline in pain severity and functional disability (P < .001). Less phonophobia, photophobia, and nausea were reported during the time taking vitamin E.
Vitamin E is generally safe at dosages up to 5500 IU/d. It is also well-tolerated, particularly when taken short term, as would be the case with menstrual migraine.
Douglas S. Paauw, MD, is the Rathmann Family Foundation Endowed Chair in Patient-Centered Clinical Education and a professor of general internal medicine at the University of Washington. He was elected to Mastership in the American College of Physicians (ACP) in 2009. He is a frequent lecturer at the ACP annual meeting, presenting yearly standing-room-only lectures on drug interactions and medical myths.
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