Sage

What it is

Sage is a shrub native to the Mediterranean and Middle East, and common sage (Salvia officinalis) is widely used as a cooking spice. The word 'sage' covers many Salvia species; Spanish sage (S. lavandulaefolia) is a separate species used in some studies. Common sage contains thujone, a compound that is toxic to the nervous system in large amounts.

What the research says

Small trials suggest common sage may reduce menopausal hot flushes, and a few small studies report better memory scores, but the evidence base is small and often manufacturer-funded. A 2023 meta-analysis of four trials called the drop in hot-flush frequency significant, but its own confidence interval crossed zero, so neither frequency nor severity was shown to change significantly. A pilot trial of a sage-rosemary-melissa mix found no overall memory benefit. The European Medicines Agency accepts sage leaf only as a traditional remedy (for indigestion, excess sweating, and mouth or throat inflammation) and limits thujone to below 6.0 mg a day. Sage essential oil has caused seizures, including in children who swallowed it by accident.

Evidence grade: Limited evidence.

What goes wrong

Two young children had generalised tonic-clonic seizures after accidental exposure to sage oil; both recovered. (Source 1)

• Case report, Very low certainty.
• Size: 2 patients.
• Who: a newborn and a toddler.
• How long: accidental exposure.
• Result: Generalised seizures, repeated in the newborn.
• Funding: not stated.

We report 2 cases, those of a newborn and a toddler, who experienced generalized tonic-clonic seizures after accidental exposure to sage oil.

Three previously healthy people had seizures linked to essential oils taken for therapy; sage oil is among 11 plant oils identified as powerful convulsants because of compounds such as thujone and camphor. (Source 2)

• Case series, Very low certainty.
• Size: 3 patients.
• Who: two adults and one child.
• How long: n/a.
• Result: Tonic-clonic seizure or tonic status.
• Funding: not stated.

A survey of the literature shows essential oils of 11 plants to be powerful convulsants (eucalyptus, fennel, hyssop, pennyroyal, rosemary, sage, savin, tansy, thuja, turpentine, and wormwood)

A toxicological review found thujone is neurotoxic and causes convulsions in animals; the best estimates for allowable intake from herbs and diet are about 3-7 mg a day. It is broken down mainly by the liver enzyme CYP2A6, which could allow interactions. (Source 3)

• Expert review, not systematic, Low certainty.
• Size: n/a.
• Who: animal and in-vitro data.
• How long: n/a.
• Result: Allowable intake estimate 3-7 mg/day.
• Funding: not stated.

CYP-associated metabolism may give rise to some potential pharmacogenetic and metabolic interaction consequences.

EMA HMPC (20 September 2016) position: sage oil equal to more than 15 g of sage leaf is reported to cause racing heart, vertigo and seizures, and daily thujone exposure must stay below 6.0 mg. (Source 4)

• Official position, Certainty not rated.
• Size: n/a.
• Who: n/a.
• How long: n/a.
• Result: Thujone limit below 6.0 mg/day.
• Funding: government (EMA)

Intake of sage oil corresponding to more than 15 g of sage leaf is reported to cause sensation of heat, tachycardia, vertigo and epileptiform convulsions (seizures).

NCCIH (April 2025) position: only small amounts of research exist, and sage may be unsafe in high doses, over long periods or in pregnancy because of thujone. (Source 5)

• Official position, Certainty not rated.
• Size: n/a.
• Who: general public.
• How long: n/a.
• Result: Position statement.
• Funding: government (NIH)

contain a component called thujone that can be toxic if consumed in large amounts; therefore, sage may be unsafe in high doses or if consumed for long periods of time.

What the evidence supports

A manufacturer-sponsored 4-week trial of fresh sage extract tablets reduced menopause symptom scores compared with placebo. (Source 6)

• Randomized trial, Low certainty.
• Size: 80 women.
• Who: menopausal women aged 48-65.
• How long: 4 weeks.
• Result: MRS fell 39.2% (p = 0.002 vs placebo); hot flush score fell 55.3%.
• Funding: industry-funded (A.Vogel)

Salvia off. distinctly reduced MRS by 39.2% from 15.3 ± 6.87 to 9.3 ± 5.75 and significantly in comparison to placebo (p = 0.002).

An open-label trial with no placebo group reported hot flushes fell by about half within four weeks on a daily fresh sage tablet. (Source 7)

• Case series, Very low certainty.
• Size: 71 women (69 ITT)
• Who: menopausal women with at least five flushes a day.
• How long: 8 weeks.
• Result: Intensity-rated flush score fell 50% at 4 weeks and 64% at 8 weeks.
• Funding: not stated in abstract (later trials by same product maker)

In the ITT population there was a significant decrease in the TSIRHF by 50% within 4 weeks and by 64% within 8 weeks (P<0.0001).

A small 4-month trial in mild-to-moderate Alzheimer's disease reported better cognitive scores with sage extract than placebo. (Source 8)

• Randomized trial, Low certainty.
• Size: 42 patients.
• Who: people aged 65-80 with mild-to-moderate Alzheimer's disease.
• How long: 16 weeks.
• Result: ADAS-cog F = 4.77, P = 0.03; CDR-SB F = 10.84, P < 0.003.
• Funding: not stated.

At 4 months, S. officinalis extract produced a significant better outcome on cognitive functions than placebo (ADAS-cog: F = 4.77, d.f. = 1, P = 0.03)

What the evidence does not support

A 2023 meta-analysis of four small trials described sage's effect on hot-flush frequency as significant, but its own confidence interval crosses zero, so neither frequency nor severity was shown to be significantly reduced. (Source 9)

• Meta-analysis, Low certainty.
• Size: 310 women in 4 studies.
• Who: postmenopausal women.
• How long: varied.
• Result: Frequency ES -1.12 (95% CI -2.37 to 0.14), I2 71%; severity ES -2.05 (95% CI -6.53 to 2.43), I2 70%.
• Funding: none declared.

Limit of this finding: The authors call the effect on hot-flash frequency 'significant', but their own 95% confidence interval (-2.37 to 0.14) includes zero, which means the pooled result is not statistically significant by the usual standard. A reader should not conclude that sage has been shown to reduce how often hot flashes happen. The analysis also rests on only 4 small studies (310 women) with high variation between them (I2 around 70%). Severity was not significantly reduced either.

Meta-analysis results showed that the effect of Salvia Officinalis on the frequency [ES=-1.12 (%95 CI:-2.37; 0.14), I2=71%] of hot flashes in postmenopausal women was significant compared to placebo

In the same meta-analysis, sage did not significantly reduce the severity of hot flushes. (Source 9)

• Meta-analysis, Low certainty.
• Size: 310 women in 4 studies.
• Who: postmenopausal women.
• How long: varied.
• Result: Severity ES -2.05 (95% CI -6.53 to 2.43)
• Funding: none declared.

Limit of this finding: The authors call the effect on hot-flash frequency 'significant', but their own 95% confidence interval (-2.37 to 0.14) includes zero, which means the pooled result is not statistically significant by the usual standard. A reader should not conclude that sage has been shown to reduce how often hot flashes happen. The analysis also rests on only 4 small studies (310 women) with high variation between them (I2 around 70%). Severity was not significantly reduced either.

but severity [ES=-2.05 (%95 CI:-6.53; 2.43), I2=70%] was not significant.

In a pilot trial, a sage, rosemary and melissa extract did not improve word recall overall compared with placebo; a benefit appeared only in an under-63 subgroup. (Source 10)

• Randomized trial, Very low certainty.
• Size: 44 healthy adults.
• Who: healthy adults, mean age 61.
• How long: 2 weeks.
• Result: No overall difference; subgroup p < 0.0123, d = 0.92.
• Funding: not stated.

Overall there were no significant differences between treatment and placebo change from baseline for immediate or delayed word recall.

Where the evidence is mixed

That trial was sponsored by the maker of the tested product, and a co-author was an employee. (Source 11)

• Randomized trial, Low certainty.
• Size: 80 women.
• Who: as above.
• How long: 4 weeks.
• Result: Funding statement.
• Funding: industry-funded.

This study was sponsored by A.Vogel, Roggwil, Switzerland, manufacturer of the tested Salvia off. preparation Menosan® Salvia .

A 2014 systematic review of eight small trials (six in healthy people, two in Alzheimer's disease) reported possible cognitive benefits from sage, but said methodological problems undermine the findings. (Source 12)

• Systematic review, Low certainty.
• Size: 8 clinical studies.
• Who: healthy adults (6 studies) and people with Alzheimer's disease (2 studies)
• How long: mostly single doses to 4 months.
• Result: No pooled estimate.
• Funding: no conflict declared.

Limit of this finding: The abstract contradicts itself: it first describes all eight studies as testing 'acute effects' of common sage 'on healthy subjects', then says two of the eight were in people with Alzheimer's disease, and six tested common or Spanish sage. So the conclusion about patients with dementia rests on two studies only, and the review pooled no numbers. The abstract's misspellings ('lavandaeluaefolia', 'Azheimer's') are in the original and are kept as written. Read this as a weak, mixed signal, not proof that sage improves memory.

Unfortunately, promising beneficial effects are debased by methodological issues, use of different herbal preparations (extracts, essential oil, use of raw material), lack of details on herbal products used.

EMA HMPC (2016) accepts sage leaf only as a traditional herbal medicine, based on long-standing use rather than proven efficacy. (Source 13)

• Official position, Certainty not rated.
• Size: n/a.
• Who: n/a.
• How long: n/a.
• Result: Traditional-use only.
• Funding: government (EMA)

The product is a traditional herbal medicinal product for use in specified indications exclusively based upon long-standing use.

Where the research disagrees

Whether sage reduces hot-flush frequency in the pooled evidence

• Moradi et al. 2023 (authors' conclusion), meta-analysis of 4 studies: Meta-analysis results showed that the effect of Salvia Officinalis on the frequency [ES=-1.12 (%95 CI:-2.37; 0.14), I2=71%] of hot flashes in postmenopausal women was significant compared to placebo (Source 9)
• NCCIH (2025), position: The results of a few small studies suggest that common sage might be helpful in reducing the frequency of hot flashes associated with menopause. (Source 5)

How much

• Reference intake: No reference intake exists; sage is not a nutrient. (Source 5)
• Upper limit: No UL for sage. EMA HMPC (2016) requires daily thujone exposure from sage leaf medicines to be below 6.0 mg; Pelkonen et al. (2013) estimated allowable thujone intake at about 3-7 mg/day. (Source 4)
• Studied: Three tablets a day, each containing 100 mg sage extract, for 3 months. (Source 14)
• Studied: Menosan tablets containing 280 mg thujone-free thick (spissum) extract of fresh sage tips, equivalent to 3,400 mg tincture, for 4 weeks. The abstract's '3'400 mg ethanolic extract' refers to the tincture equivalent, not the extract dose. (Source 15)
• Studied: Sage extract 60 drops/day for 4 months in Alzheimer's disease. (Source 16)

A common belief, and what the research shows

The belief: Sage is a harmless kitchen herb, so concentrated sage products are safe in any amount.

What the research shows: NCCIH says sage is 'likely safe in the amounts commonly found in foods', but that thujone 'can be toxic if consumed in large amounts'. EMA reports sage oil equal to more than 15 g of leaf 'is reported to cause sensation of heat, tachycardia, vertigo and epileptiform convulsions (seizures).'

Questions and answers

What is it?

Sage is a Mediterranean shrub. Common sage (Salvia officinalis) is the cooking herb; Spanish sage is a different species. (Source 5)

What does it do in the body?

Small studies suggest it may reduce hot flushes and may improve memory scores, but there is not enough research for firm conclusions. (Source 5)

Is it good or bad for you?

Food amounts are considered safe, and trial doses were used for up to 8 weeks. High doses, long use, sage oil and use in pregnancy carry risk because of thujone. (Source 5)

How do you get more of it?

Sage is eaten as a spice; trials gave sage extract tablets, for example three 100 mg tablets a day. (Source 14)

If it is harmful, what reduces it?

The harmful part is thujone. The EMA requires products to state their thujone content and keep daily exposure below 6.0 mg, and it recommends low-thujone chemotypes. (Source 4)

Why might someone be low in it or missing it?

Does not apply. Sage is not a nutrient, so there is no deficiency. (Source 5)

We searched: PubMed and NCCIH; no deficiency concept exists for a non-essential herb.

Which whole foods contain it or feed it?

Sage itself is the food source; it is used in cooking as a spice. (Source 5)

What happens if you do not have it?

Nothing is known to happen; sage is not essential. (Source 5)

We searched: PubMed and NCCIH; no deficiency syndrome is described.

How can you test for it?

There is no clinical test for sage intake or status. (Source 3)

We searched: PubMed searches on sage and thujone biomonitoring; the closest review says human dose-concentration-effect relationships remain a key knowledge gap.

References

1. Pediatr Neurol. Toxicity of Salvia officinalis in a newborn and a child: an alarming report. 2011. PMID 21907890, DOI 10.1016/j.pediatrneurol.2011.05.012. Read the source
2. J Neurol. Plant-induced seizures: reappearance of an old problem. 1999. PMID 10460442, DOI 10.1007/s004150050429. Read the source
3. Regul Toxicol Pharmacol. Thujone and thujone-containing herbal medicinal and botanical products: toxicological assessment. 2013. PMID 23201408, DOI 10.1016/j.yrtph.2012.11.002. Read the source
4. European Medicines Agency, Committee on Herbal Medicinal Products. European Union herbal monograph on Salvia officinalis L., folium (EMA/HMPC/277152/2015). 2016. Read the source
5. National Center for Complementary and Integrative Health (NIH). Sage. 2025. Read the source
6. Heliyon. Effectiveness of Menosan® Salvia officinalis (results). 2021. PMID 33615001, DOI 10.1016/j.heliyon.2021.e05910. Read the source
7. Adv Ther. First time proof of sage's tolerability and efficacy in menopausal women with hot flushes. 2011. PMID 21630133, DOI 10.1007/s12325-011-0027-z. Read the source
8. J Clin Pharm Ther. Salvia officinalis extract in the treatment of patients with mild to moderate Alzheimer's disease: a double blind, randomized and placebo-controlled trial. 2003. PMID 12605619, DOI 10.1046/j.1365-2710.2003.00463.x. Read the source
9. Int J Community Based Nurs Midwifery. The Effect of Salvia Officinalis on Hot Flashes in Postmenopausal Women: A Systematic Review and Meta-Analysis. 2023. PMID 37489230, DOI 10.30476/IJCBNM.2023.97639.2198. Read the source
10. Phytomedicine. A randomised double-blind placebo-controlled pilot trial of a combined extract of sage, rosemary and melissa, traditional herbal medicines, on the enhancement of memory in normal healthy subjects, including influence of age. 2018. PMID 29433682, DOI 10.1016/j.phymed.2017.08.015. Read the source
11. Heliyon. Effectiveness of Menosan® Salvia officinalis (conflict of interest statement). 2021. PMID 33615001, DOI 10.1016/j.heliyon.2021.e05910. Read the source
12. CNS Neurosci Ther. Systematic review of clinical trials assessing pharmacological properties of Salvia species on memory, cognitive impairment and Alzheimer's disease. 2014. PMID 24836739, DOI 10.1111/cns.12270. Read the source
13. European Medicines Agency, Committee on Herbal Medicinal Products. European Union herbal monograph on Salvia officinalis L., folium (indications). 2016. Read the source
14. J Family Med Prim Care. The effect of Salvia officinalis extract on symptoms of flushing, night sweat, sleep disorders, and score of forgetfulness in postmenopausal women. 2020. PMID 32318472, DOI 10.4103/jfmpc.jfmpc_913_19. Read the source
15. Heliyon. Effectiveness of Menosan® Salvia officinalis (full text, methods: study medication). 2021. PMID 33615001, DOI 10.1016/j.heliyon.2021.e05910. Read the source
16. J Clin Pharm Ther. Salvia officinalis extract in the treatment of patients with mild to moderate Alzheimer's disease (methods). 2003. PMID 12605619, DOI 10.1046/j.1365-2710.2003.00463.x. Read the source