LAUSR

Thank you for the opportunity to respond to Prof. Diener’s letter [1]. While the authors were aware of the referenced article in Cephalalgia Reports [2] at the time of writing, there were constraints placed on word count of the manuscript that prevented detailed discussion of this paper and its implications for patients and physicians who recommend the product. We are grateful for Prof. Diener’s observation and for the opportunity to discuss it now in this forum. The authors’ concern regarding butterbur safety stems not from a lack of awareness regarding the proprietary method by which Petadolex® removes pyrrolizidine alkaloids (which unfortunately are not available to the general public for review), but rather from a concern about the capacity of the individual patient and front-line healthcare practitioner to differentiate ‘Petadolex®’ from the number of ‘butterbur’ compounds that exist in the North American and international markets. While the literature [2] suggests Petadolex® is free of pyrrolizidine alkaloids, it remains an issue whether the consumer will safely and reliably be able to find this unique product if and when advised to use butterbur in the management of migraine. The authors differ with respect to Prof. Diener’s statement [1] “despite the safety uncertainties of butterbur products that do not contain Petadolex®, it is still possible to recommend butterbur for migraine prophylaxis”. While recognizing that some practitioners may feel safe in recommending ‘Petadolex®’ for the treatment of migraine, the authors do not feel it is safe to recommend ‘butterbur’ in general for migraine prophylaxis as that may include not only Petadolex® but also myriad other compounds that have not been rigorously tested for safety and efficacy. In addition, the authors have concerns that direct advice of a brand-name product to patients/consumers, either through this review or other guidelines, suggesting Petadolex® above other butterbur compounds is safe, may improperly be interpreted to suggest that other butterbur compounds on the North American and international markets are safe, and this indeed may not be the case, as we discussed in our review [3]. That being said, the authors recognize the laudable efforts the manufacturers of Petadolex® have undertaken to demonstrate the safety of their product [2] and to communicate this to the neurology community at large, which cannot be said of other producers of butterbur extracts or preparations worldwide. There is also the ethical issue of physicians, especially those who are fortunate to have the opportunity to write articles and guidelines to help guide patient care, directly recommending specific brand names of nutraceuticals/medications to patients and practitioners. There is a complex but often fruitful relationship to be had between industry and medicine; however, it should not occur at the expense of impartiality and ethical physician prescribing practices. To be clear, the authors of the review (Rajapakse and Davenport) have no commercial interests or conflicts to declare with the Petadolex® company, or with any competitor of the Petadolex® product. Our concerns solely lie with the safety of patients and the clarity of recommendations made regarding Petadolex® and This reply refers to the article available at https ://doi.org/10.1007/ s4026 3-019-00635 -1.