Quick answer

Echinacea's most common side effects are digestive, such as stomach upset and nausea. Trouble sleeping and skin rashes are reported too, and allergic reactions are rare but can be severe, especially in people prone to allergies. European regulators advise using one form for no more than 10 days at a time.^1,2,3

Key facts

Echinacea belongs to the daisy family, with ragweed, daisies and sunflowers.²
European regulators list hives, itching and facial swelling among possible reactions.³
Isolated reports link echinacea to raised liver enzymes, possibly because of a contaminant.^4,5
NIH says echinacea might lower levels of some medicines and weaken immune-suppressing drugs.⁴

Common side effects

The most common side effects are digestive: stomach upset, nausea, stomach pain and diarrhea.^1,2

Trouble sleeping has been reported.^1,4

NIH calls echinacea's side effects few. Neither NIH nor the European monograph gives a rate for each one, so this list shows what has been reported, not how often.^3,4

Allergic reactions

Skin rashes occur, and allergic reactions are rare but can be severe. European regulators list rash, hives, itching and facial swelling, and rarely severe reactions such as anaphylaxis, especially in people prone to allergies.^2,3,4

In a trial in children, some developed rashes that may have been allergic reactions.²

The risk is higher if you react to ragweed, daisies or sunflowers, and in people with asthma, eczema or hay fever, a tendency European regulators call atopy. For anyone allergic to daisy-family plants, the monograph says not to use echinacea at all.^2,3

The liver

There are isolated reports of raised liver enzymes and liver injury linked to echinacea. NIH notes they may have been caused by a contaminant or the way the product was prepared.^4,5

The NIH summaries call these reports isolated and give no count of cases. If you have a liver condition, ask your doctor before taking any herbal product.^4,5

Autoimmune conditions and immune-suppressing medicines

European regulators say a link between echinacea and autoimmune conditions cannot be ruled out.³

Ask your pharmacist or doctor first

Echinacea might make medicines that suppress the immune system work less well, because it may stimulate immune activity. NIH and NCCIH both name this as a possible interaction on theoretical grounds.^1,2,4

Expected from how the two work, not shown in studies

European regulators do not recommend echinacea for people with an autoimmune condition, an immune deficiency, immune suppression, a white blood cell disorder or a progressive systemic disorder.³

Other medicines

Ask your pharmacist or doctor first

The warfarin label names echinacea among botanicals that can interact with warfarin through CYP450 liver enzymes, and asks for more frequent INR checks whenever a botanical is started or stopped. MedlinePlus also lists echinacea among herbal products that may interact with warfarin.^6,7

On the medicine's label

In two small studies in healthy volunteers, taking echinacea for 8 to 28 days lowered blood levels of midazolam, a test medicine cleared by the liver enzyme CYP3A, by about a quarter.^8,9

In the 8-day study, echinacea root slowed the body's clearance of caffeine, which the enzyme CYP1A2 handles, by about a quarter.⁸

NCCIH calls the evidence on medicines broken down by the liver conflicting, and names caffeine as a theoretical concern too. Ask your pharmacist before combining echinacea with any regular medicine.²

Pregnancy and breastfeeding

NIH says echinacea's safety in pregnancy is not known and that experts recommend against it. NCCIH says some studies suggest it is possibly safe for up to 7 days in the first trimester, and that little is known about breastfeeding. Our guide for women sets out the pregnancy studies.^2,4

Questions people ask

Is echinacea safe to take?

For most adults over short periods, NCCIH calls it likely safe. The main concerns are allergic reactions, digestive upset and trouble sleeping, and some people should avoid it or ask a doctor first.^1,2

Can I take echinacea at night?

No study has compared taking it at night with taking it during the day. Trouble sleeping is one of its reported side effects, so if you sleep worse after starting it, echinacea may be the cause.¹

Is echinacea safe if I have an autoimmune condition?

European regulators do not recommend it for people with autoimmune conditions, and they say a link between echinacea and these conditions cannot be ruled out. Ask your doctor first.³

What are the side effects of long-term use?

They are largely unknown, because studies have been short. The longest one NIH describes gave echinacea to young, healthy adults for 4 months.^2,4

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Sources

This page is information, not medical advice. Talk to your doctor or pharmacist about your own situation.