Butterbur (scientific name Petasites hybridus) is a plant in the Asteraceae family, also called Compositae, or daisy family that grows in wetlands of the temperate regions in North America. Native Americans traditionally used butterbur for inflammation and headaches. The rhizomes and leaves of the plant contain the highest concentration of plant based compound called pyrrolizidine alkaloids which are toxic to the liver and are a known carcinogens which has caused cancer in animals and may cause cancer in humans (1, 2). It is therefore vitally important that a butterbur (Petasites hybridus) supplement has had the pyrrolizidine alkaloids removed. The label must state for instance that the product is “standardized to a guaranteed 15% petasins and certified free of pyrrolizidine alkaloids.”
Butterbur (Petasites hybridus) and migraines:
A detailed study of nutritional history and identification of food triggers led the authors of a study to specifically recommend Petasites hybridus as one of several supplements which may be effective for migraines (7).
Butterbur has been established as effective for migraine prevention according to a report by The Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. (3) This source also outlines other migraine therapies as well which may be accessed at: http://guideline.gov/content.aspx?f=rss&id=36897
Butterbur has been shown to have beneficial effects for the treatment of migraine headaches in a review of two randomized-controlled trials (n=293) testing the effectiveness of Petadolex a marketed version of P. hybridus. After treatment over 3-4 months, results indicate that compared to a low dose (100mg) of Petadolex, individuals taking a higher dose of 150 mg reported a fewer number of migraines and a greater number reported a more than 50% improvement in migraines. (4)
Researchers performed a study of the effectiveness of butterbur for the treatment of migraine headaches in 245 sufferers. Participants received either 50 mg twice daily of P. hybridus, 75 mg twice daily, or placebo. Over the 4 months of the study, the frequency of migraine attacks decreased in all three groups: 36% in the 75 mg group, 48% in the 50 mg group, and 26% in the placebo group. However, the group receiving the higher dose of butterbur extract showed significantly greater improvement than those in the placebo group. The lower dose of butterbur failed to prove significantly more effective than placebo. Additionally, P. hybridus was shown to cut the frequency of migraine headaches by at least 50% in 68% of patients in the 75-mg arm and only 49% in the placebo arm. (5)
The effectiveness of Butterbur root extract (Petadolex) for treatment of migraine headaches was examined in this study which randomized 33 participants to received 50 mg butterbur twice a day and 27 participants to placebo. After 3 months, the frequency of migraine attacks significantly decreased in the treatment group from an average of 3.4 at the beginning of the study to 1.8. The placebo group experienced a non-significant decrease from 2.9 to 2.6. Additionally, butterbur was shown to cut the frequency of migraine headaches by at least 50% in 45% of patients in treatment arm and only 15% in the placebo arm. (6)
Butterbur (Petasites hybridus) and allergic rhinitis:
A randomized controlled trial (RCT) using butterbur vs. antihistamine for allergic rhinitis: A RCT trial including 125 participants showed that the herbal agent butterbur (Petasites hybridus) has beneficial effects in patients with seasonal allergic rhinitis possibly comparable to the antihistamine Zyrtec (cetirizine). For two weeks, patients were randomized to either one tablet butterbur (petasites carbon dioxide extract ZE 339 standardized to 8.0 mg of total petasine per tablet), four times daily herb extract (n=61) or one tablet cetirizine (n=64) in the evening. The SF-36 questionnaire, a medical outcome health questionnaire, was used as a self-assessment tool. The questionnaire also includes the physician\’s clinical global impression scale (CGI) with a five-point score for comparing current severity of the condition with that of the previous year. Improvements in both the SF-36 and CGI scores were similar in both groups. The overall incidence of adverse events was similar for the two treatment groups. However, two-thirds of the adverse events for the cetirizine group were drowsiness and fatigue — symptoms not reported in the butterbur group. Fatigue occurred less in the butterbur group than the cetirizine group, headache occurred in two patients of each group, and elevated liver enzymes occurred in 1 patient of the butterbur group. (8)
Butterbur leaf extract Ze 339 (carbon dioxide extract from the leaves of Petasites hybridus L., 8 mg petasines per tablet) was given to 580 patients with seasonal allergic rhinitis or nasal allergies responsible for sneezing, congestion, runny nose, and itchy nose. Participants were treated with an average of 2 tablets of Ze 339 daily for 2 weeks. At the end of the study, symptoms (rhinorrhea, sneezing, nasal congestion, itchy eyes and nose, red eyes, and skin irritation) of seasonal allergic rhinitis significantly improved in 90% of patients. Additionally, effectiveness, tolerability, and quality of life improvement was reported by 80%, 92% and 80% of patients, respectively. Anti-allergy medication given in combination with Ze 339 showed no improvement compared to Ze 339 alone. Side effects were reported in 3.8% of patients with mostly gastrointestinal complaints. (9)
Butterbur (Petasites hybridus) and asthma:
Butterbur (Petasites hybridus) root powder is a supplement that contains petasins, a group of anti-inflamatory compounds. In a German prospective, non-randomized, open trial, 80 asthma sufferers (64 adults and 16 children/adolescents) who took 50 mg butterbur extract (Petadolex) 3 times a day (children: 50-150 mg daily, depending on age) saw the number, duration, and severity of their asthma attacks decrease during an eight-week study period. During the first two months the patients were treated with the extract, followed by two months during which the intake of the extract was optional. Patients were permitted to continue with their regular asthma medications for the entire duration of the study. At the end of the study, measure of lung function (peak flow, forced expiratory volume [FEV1]) and asthma medication use improved. The average improvement for peak flow was 28.5% and for FEV1 it was 11.3%. Of the patients taking inhaled asthma medication in addition to butterbur extract, 43% reduced the amount of medication used while they were taking butterbur extract. The study authors speculated that butterbur extract might be effective both as a stand-alone asthma treatment and in combination with other asthma medications. The flaw of the study was that it was not a randomized or blinded design. (10)
Assessment and Plan: Butterbur, Petasites hybridus
- The most common dose of Butterbur is 50-150mg three times daily. When Butterbur is purchased, make sure that pyrrolizidine alkaloids have been removed, which that are potentially hepatotoxic and carcinogenic, and are standardized to a guaranteed 15% petasins.
- Butterbur without pyrrolizidine alkaloids removed was reported to cause liver enzyme elevation in 1 out of 61 patients when used for 2 weeks in one study. This may have been due to pyrrolizidine alkaloids found naturally in the herb. Side effects were reported in 3.8% of patients with mostly gastrointestinal complaints. If a patient decides to take butterbur (Petasites hybridus) supplement, it is vitally important that the pyrrolizidine alkaloids have been removed, and the label states that the product is “standardized to a guaranteed 15% petasins and certified free of pyrrolizidine alkaloids.”
- Butterbur (Petasites hybridus) is established in research to be effective for migraine prevention. After treatment over 3-4 months, research indicates that patients taking doses of 100 mg to 150 mg of butterbur (Petasites hybridus) extract per day reported a fewer number of migraines and some reported a more than 50% improvement in migraines.
- Butterbur (Petasites hybridus) helps alleviate symptoms in allergic rhinitis patients without the fatigue and drowsiness seen with the antihistamine Zyrtec (cetirizine). The study included petasites carbon dioxide extract ZE 339, a butterbur (Petasites hybridus) extract standardized to 8.0 mg of total petasine per tablet, four times daily.
- In a German prospective, non-randomized, open trial, 80 asthma sufferers (64 adults and 16 children/adolescents) who took 50 mg butterbur extract (Petadolex®) 3 times a day (children: 50-150 mg daily, depending on age) saw the number, duration, and severity of their asthma attacks decrease during an eight-week study period. The dose for each age group was not described in the study. Petadolex®, softgel capsules (manufactured by Weber & Weber International GmbH & Co. KG, Germany) contains 50 mg of a standardized lipophilic extract of the rhizome of Petasites hybridus. Of the patients taking inhaled asthma medication in addition to butterbur extract, 43% reduced the amount of medication used while they were taking butterbur extract. The manufacturing process of Petadolex® removes pyrrolizidine alkaloids that are potentially hepatotoxic and carcinogenic.
References:
1.Wildi E, Langer T, Schaffner W, Büter KB.Quantitative analysis of petasin and pyrrolizidine alkaloids in leaves and rhizomes of in situ grown Petasites hybridus plants. Planta Med. 1998 Apr;64(3):264-7. http://www.ncbi.nlm.nih.gov/pubmed/17253240
2.Ayd?n AA, Zerbes V, Parlar H, Letzel T.The medical plant butterbur (Petasites): analytical and physiological (re)view. J Pharm Biomed Anal. 2013 Mar 5;75:220-9. http://www.ncbi.nlm.nih.gov/pubmed/23277154
3.Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012 Apr 24;78(17):1346-53. http://guideline.gov/content.aspx?f=rss&id=36897
4.Agosti R, Duke RK, Chrubasik JE, Chrubasik S. Effectiveness of Petasites hybridus preparations in the prophylaxis of migraine: a systematic review. Phytomedicine. 2006 Nov;13(9-10):743-6. Epub 2006 Sep 20. http://www.ncbi.nlm.nih.gov/pubmed/16987643
5.Lipton RB, Gobel H, Einhaupl KM, Wilks K, Mauskop A. Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Neurology. 2004 Dec 28;63(12):2240-4. http://www.ncbi.nlm.nih.gov/pubmed/15623680
6.Diener HC, Rahlfs VW, Danesch U. The first placebo-controlled trial of a special butterbur root extract for the prevention of migraine: reanalysis of efficacy criteria. Eur Neurol. 2004;51(2):89-97. http://www.ncbi.nlm.nih.gov/pubmed/14752215
7.Sun-Edelstein C, Mauskop A., Foods and supplements in the management of migraine headaches. Clinical Journal of Pain. 2009 Jun;25(5):446-52. http://www.ncbi.nlm.nih.gov/pubmed/19454881
8.Schapowal A. Petasites Study Group. Randomised controlled trial of butterbur and cetirizine for treating seasonal allergic rhinitis. BMJ 2002 Jan 19;324(7330):144-6. http://www.ncbi.nlm.nih.gov/pubmed/11799030
9.Kaufeler R, Polasek W, Brattstrom A, Koetter U. Efficacy and safety of butterbur herbal extract Ze 339 in seasonal allergic rhinitis: postmarketing surveillance study. Adv Ther. 2006 Mar-Apr;23(2):373-84. http://www.ncbi.nlm.nih.gov/pubmed/16751170
10.Danesch UC. Petasites hybridus (Butterbur root) extract in the treatment of asthma–an open trial. Altern Med Rev. 2004 Mar;9(1):54-62. http://www.altmedrev.com/publications/9/1/54.pdf