Is it safe for a patient with epilepsy, taking Keppra (levetiracetam) and Dilantin (phenytoin), to use valerian root for anxiety or insomnia?

Valerian Root with Keppra and Dilantin: Safety Concerns

I strongly advise against using valerian root in combination with Keppra (levetiracetam) and Dilantin (phenytoin) due to potential drug interactions, lack of proven efficacy, and theoretical risks of altered seizure control in epilepsy patients.

Critical Safety Concerns in Epilepsy Patients

Theoretical Anticonvulsant Properties Create Unpredictability

• Valerian contains isovaleric acid, a substance structurally analogous to valproic acid (a known antiepileptic drug), which may possess anticonvulsant properties 1
• Historical reports from the 16th-19th centuries suggested valerian was used to treat epilepsy, with some claiming anticonvulsant effectiveness 1
• The uncertain chemical composition and variable content of valerian preparations make it impossible to predict how it might interact with established antiepileptic medications 1
• Adding an unregulated substance with potential anticonvulsant effects to a stable seizure medication regimen creates unpredictable pharmacodynamic interactions that could destabilize seizure control 1

CNS Depression and Sedation Risks

• Valerian has documented sedative properties through both valepotriates and sesquiterpenes 2
• The American Society of Anesthesiologists recommends discontinuing valerian at least 2 weeks before surgery due to its sedative properties and potential for additive CNS depression 3
• When combined with other CNS-active medications (like antiepileptic drugs), valerian may potentiate sedation and cognitive impairment 3
• This is particularly concerning because both Keppra and Dilantin can cause sedation, dizziness, and cognitive effects—adding valerian compounds these risks 4

Lack of Proven Efficacy

• The American Academy of Sleep Medicine explicitly recommends against using valerian for sleep onset or sleep maintenance insomnia (weak recommendation) 4
• A 2024 umbrella review found no evidence of efficacy for treating insomnia, despite valerian's widespread use 5
• While some subjective improvements in sleep quality have been reported, objective measurements show no clinically significant benefits 4, 5
• The risk-benefit ratio is unfavorable: potential drug interactions and seizure destabilization versus no proven therapeutic benefit 4, 5

Better Alternatives for This Patient

For Sleep Problems

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment before considering any medications or supplements 6
• If pharmacotherapy becomes necessary, low-dose doxepin (3-6mg) is most appropriate for sleep maintenance insomnia with a favorable safety profile 6
• Ramelteon 8mg may be considered for sleep onset insomnia 6
• Sleep hygiene education and stimulus control therapy are evidence-based non-pharmacological interventions 6

For Anxiety

• Evidence-based psychotherapy and FDA-approved medications have more robust safety profiles than herbal supplements in patients with epilepsy 3
• The American Psychiatric Association notes that standard treatments for anxiety disorders have better-established efficacy and safety data 3

Critical Pitfalls to Avoid

• Never assume herbal supplements are "safe" or "natural" alternatives in patients on antiepileptic drugs—they can have significant pharmacological effects 1
• The variable quality and chemical composition of valerian preparations means dosing is unpredictable, even if a patient insists on trying it 5, 1
• Patients may not volunteer information about herbal supplement use—specifically ask about valerian and other supplements 7
• Even though valerian has a generally good safety profile in healthy adults, this does not translate to safety in epilepsy patients on multiple antiepileptic drugs 7, 5

Clinical Bottom Line

The combination of theoretical anticonvulsant properties, CNS depressant effects, lack of proven efficacy, and potential to destabilize seizure control makes valerian root inappropriate for patients taking Keppra and Dilantin 4, 3, 5, 1. Direct the patient toward evidence-based treatments like CBT-I for sleep problems or standard anxiolytics if anxiety is the concern 6, 3.