Feverfew for migraine? A new and rather useless review of the evidence

I came across a new systematic review of the herbal remedy, FEVERFEW, as a preventative treatment for migraine. Here is the abstract:

Review just published in ‘The American Journal of Natural Medicines, Facts’

Migraine, a neurological condition, affects approximately 1.1 billion people worldwide, making it the third leading cause of disability. It significantly impacts quality of life and incurs an annual economic burden exceeding $78 billion in the United States. This systematic review and meta-analysis aims to evaluate the efficacy of Feverfew Dietary Supplement in migraine prophylaxis, with migraine frequency considered as the primary outcome. Three trials (n=237) were included in the meta-analysis (MA) of migraine frequency, and an additional three trials were synthesized narratively in the systematic review. In the MA, feverfew showed a non-significant reduction in migraine frequency compared to placebo (Overall effect size, Cohen’s d: -0.19; 95% CI: -0.52 to 0.14; I² = 34%, p = 0.26). These findings suggest that Feverfew might offer some benefit in individual patients, but given the small, non-significant effect size, it should not be recommended as a primary prophylactic agent over established treatments. Feverfew may not be effective as a standalone prophylactic supplement for migraines; however, its potential in combination therapies seems promising and requires further evaluation. Larger trials with standardized parthenolide content and extended durations are necessary to clarify feverfew’s definitive role in migraine prophylaxis.

The subject is no doubt interesting: migraine is a common contition that severely reduces quality of life and is difficult to treat or prevent. Thus an effective herbal remedy would be more than welcome. Based on such considerations, my co-workers and I had conducted a Cochrane review which was last updated in 2015. Here is its abstract:

Our Cochrane Review of 2015

Background: This review is an update of a previously published review in the Cochrane Database of Systematic Reviews on ‘Feverfew for preventing migraine’ (2004, Issue 1). Feverfew (Tanacetum parthenium L.) extract is a herbal remedy, which has been used for preventing attacks of migraine.

Objectives: To systematically review the evidence from double-blind randomised controlled trials (RCTs) assessing the clinical efficacy and safety of feverfew monopreparations versus placebo for preventing migraine.

Search methods: 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.

Selection criteria: We included randomised, placebo-controlled, double-blind trials assessing the efficacy of feverfew monopreparations for preventing migraine in patients 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.

Data collection and analysis: 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 (BW and MHP for this update, MHP and EE for the original version) independently selected studies, assessed methodological quality and extracted data. We resolved disagreements concerning evaluation of individual trials through discussion.

Main results: We identified one new study for this update, resulting in six trials (561 patients) meeting the inclusion criteria. Five of the six trials reported on the main outcome, migraine frequency. Although five 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 version of the review is rigorous and larger (n = 218), using a stable feverfew extract at a dose determined by a previous dose-finding trial. It reports 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, resulting in a difference in effect between feverfew and placebo of 0.6 attacks per month. For the secondary outcome measures intensity and duration of migraine attacks, incidence and severity of nausea and vomiting, and global assessment no statistically significant differences were reported. Results of previous trials are not convincing: three trials reporting positive effects of feverfew are 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, most commonly gastrointestinal complaints and mouth ulcers, were reported in the included trials.

Authors’ conclusions: 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.

The question that I ask myself is this: what exactly does the new review add to the existing knowledge?

I fear, the answer is VERY LITTLE! Arguably, the new review is even less rigorous, transparent, thorough and informative than our paper.

If that is so, why conduct and publish it?

The process of doing this is an unethical waste of resources, and the habit of publishing redundant papers is irritating and arguably also unethical.

All this would be rather trivial, of course, if not for the fact that this form of science abuse is happening all the time in the realm of so-called alternative medicine. Responsible journal editors and reviewers should remember that they have the duty to prevent it.