Comparative Efficacy of Acupuncture-Based Interventions for Cervicogenic Headache: A Systematic Review and Network Meta-Analysis

Abstract

Purpose To compare the relative efficacy of acupuncture-based interventions for cervicogenic headache and identify approaches that may improve overall efficacy rate and pain intensity. Methods PubMed, Embase, the Cochrane Library, Web of Science, and CNKI were searched from inception through September 26, 2026 for randomized controlled trials. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2 tool. A frequentist random-effects network meta-analysis synthesized direct and indirect evidence. Outcomes were the study-defined overall efficacy rate and pain intensity measured with the Visual Analog Scale (VAS). Treatment rankings, sensitivity analyses, small-study effects, and confidence in network estimates using the Confidence in Network Meta-Analysis (CINeMA) framework were evaluated. Results Twenty-nine randomized trials were included. All 29 contributed to the overall efficacy rate network, and 16 trials (1300 participants) contributed to the VAS network. Compared with conventional acupuncture, needle-knife therapy, Fu’s subcutaneous needling (FSN), fire needling, warm acupuncture, and special manual acupuncture significantly improved the overall efficacy rate. Needle-knife therapy ranked highest, followed by FSN and fire needling. For pain intensity, fire needling produced the largest reduction versus conventional acupuncture (MD, −1.88; 95% CI, −2.70 to −1.05), followed by FSN, special manual acupuncture, and warm acupuncture. Needle-knife therapy did not significantly reduce VAS scores compared with conventional acupuncture. Sensitivity analyses generally supported the findings, although several estimates were influenced by individual studies. According to CINeMA, confidence in the network estimates ranged from moderate to very low for both outcomes, and no comparison achieved high confidence. Conclusion Fire needling and FSN showed the most consistently favorable estimates across the two outcomes. Needle-knife therapy may improve the overall efficacy rate, but its advantage for pain relief remains uncertain. Because none of the evaluated comparisons achieved high confidence according to CINeMA, larger multicenter randomized trials with standardized outcomes and longer follow-up are needed.