MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Lots of alternative therapies are advocated for migraine. Few of them are supported by good evidence. An exception could be the herbal remedy FEVERFEW.

This review is an update of a previously published review in the Cochrane Database of Systematic Reviews on ‘Feverfew for preventing migraine’. Feverfew (Tanacetum parthenium L.) extract is a herbal remedy, which has been used for preventing attacks of migraine. Our aim was to systematically review the evidence from double-blind, randomised, clinical trials (RCTs) assessing the clinical efficacy and safety of feverfew monopreparations versus placebo for preventing migraine.

For this updated version of the review we searched CENTRAL, MEDLINE, EMBASE and AMED to January 2015. We contacted manufacturers of feverfew and checked the bibliographies of identified articles for further trials.

We included randomised, placebo-controlled, double-blind trials assessing the efficacy of feverfew monopreparations for preventing migraine in migraine sufferers of any age. We included trials using clinical outcome measures, while we excluded trials focusing exclusively on physiological parameters. There were no restrictions regarding the language of publication.

We systematically extracted data on patients, interventions, methods, outcome measures, results and adverse events. We assessed risk of bias using the Cochrane ‘Risk of bias’ tool and evaluated methodological quality using the Oxford Quality Scale developed by Jadad and colleagues. Two review authors independently selected studies, assessed methodological quality and extracted data. We resolved disagreements concerning evaluation of individual trials through discussion.

We identified one new study for this update, resulting in a total of 6 trials (561 patients) meeting the inclusion criteria. Five of the 6 trials reported on the main outcome measure which was migraine frequency. Although 5 of the trials were generally of good methodological quality, all studies were either of unclear or high risk of bias with regards to sample size. Pooled analysis of the results was not possible due to the lack of common outcome measures and heterogeneity between studies in terms of participants, interventions and designs. The most recent trial added to this update was rigorous and larger (n = 218) than previous studies. It used a stable feverfew extract at a dose determined by a previous dose-finding trial. It reported that feverfew reduced migraine frequency by 1.9 attacks from 4.8 to 2.9 and placebo by 1.3 from to 4.8 to 3.5 per month. This difference in effect between feverfew and placebo was thus 0.6 attacks per month. For the secondary outcome measures such as intensity and duration of migraine attacks, incidence and severity of nausea and vomiting, and global assessment no statistically significant differences between feverfew and placebo were reported.

The results of previous trials were not convincing: three trials reporting positive effects of feverfew were all of small sample size (17 to 60 participants), while two rigorous trials (n = 50, 147) did not find significant differences between feverfew and placebo.

Only mild and transient adverse events of feverfew, most commonly gastrointestinal complaints and mouth ulcers, were reported in the included trials.

We concluded that, since the last version of this review, one larger rigorous study has been included, reporting a difference in effect between feverfew and placebo of 0.6 attacks per month. This adds some positive evidence to the mixed and inconclusive findings of the previous review. However, this constitutes low quality evidence, which needs to be confirmed in larger rigorous trials with stable feverfew extracts and clearly defined migraine populations before firm conclusions can be drawn. It appears from the data reviewed that feverfew is not associated with any major safety concerns.

So, good or bad news for migraine sufferers? I suppose it depends on whether you are an optimist or a pessimist. I would say that, considering the mostly bad news about alternative medicine for migraine, it is relative good news: patients who want to try something ‘natural’ could do so, particularly in view of the lack of serious risks.

5 Responses to Feverfew: hope for migraine sufferers?

  • Still a weak signal in a lot of noise. Would this even be enough evidence to try to isolate an active chemical in the mix? Given the variability of herbal preparations in the US any conclusions of efficacy are even more problematical. As you indicate the risk is low enough to try but if it “works” once there is little confidence the next batch will give the same result.

    • isolation of the active constituent is the logical way forward. it sometimes works. other times it doesn’t, particularly, if there are more than one active ingredients. for feverfew, parthenolide is thought to be the active principle, and this approach might work. I do not know whether it has been tried but I assume it has.

  • I suppose you’ve found one of the twice a day that a stopped clock is right 🙂

    Speaking as someone with a number of migraineurs in my family, a reduction of 0.6 attacks per month is a positively enormous amount of human suffering avoided. If further refinement of the active compound can improve on that, this is an amazing result.

    • @Grant Gould
      Agreed to some extent, but just taking any capsule — feverfew or placebo — reduced migraine frequency by at least 1.3 attacks a month, which is more impressive in terms o human suffering than the 0.6 feverfew vs. placebo difference. That difference was statistically significant, but not my idea of ‘amazing’. Side-effects possibly related to drug were 9/107 (8.4%) with feverfew and 11/108 (10.2%) with placebo, making the placebo more ‘toxic’ than the active therapy. That’s not a statistically significant difference, but do contemplate how even an exact repeat of a trial with such small differences might come out with the placebo slightly more efficacious and less toxic… yet it’s got nothing active in it!

  • I suffered from frequent migraines (around 50 per year) for three and a half years and suffered terrible fatigue after each episode. Acupuncture reduced the attacks by about half – but then for some reason stopped working after a couple of years. Since taking 200mg of Feverfew twice daily for six months my attacks have become much less frequent and much less severe – so much so that they don’t interfere with my day – i.e. I don’t need to go and lie down in a darkened room and I don’t suffer from fatigue for days afterwards. Sometimes they are barely perceptible. Having unsuccessfully tried various drug treatments (beta blockers, Pizotifen) I can honestly say that feverfew has given me my life back.

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