A Commentary on Efficacy of Acupuncture and Pharmacotherapy for Migraine Prophylaxis: A Systematic Review and Meta-Analysis [Letter]

Dear editor

We read with great interest the article entitled “Efficacy of Acupuncture and Pharmacotherapy for Migraine Prophylaxis: A Systematic Review and Meta-Analysis” by Liu et al.¹ The authors conducted a meta-analysis of 19 randomized controlled trials involving 2296 patients. This study compared acupuncture with pharmacotherapy for migraine relief. Acupuncture proved superior to drugs across several efficacy measures. However, after a careful review of the study, we identified some methodological limitations that merit further discussion.

Inaccurate Description of Bias Risk Assessment Tool

The methods section misdescribed the Cochrane RoB tool, citing eight dimensions while assessing only seven actually. Second, this study’s PROSPERO registration (CRD42024521428) claimed RoB-2 usage, conflicting with the actual situation. Compared to the previous version, RoB-2 significantly enhances rigor through structured signaling questions, expanded applicability to trial designs, the introduction of automated tools, and overall risk assessment.² This discrepancy may compromise methodological quality assessment. Therefore, it is suggested to explain the reasons for the actual version of the tool used.

Cultural Bias in Adverse Events and Withdrawals

Although the acupuncture group had a lower incidence of adverse events and withdrawal rate, it should be noted that of the 19 included studies, only 2 were from Europe (Germany and Italy), with the rest conducted in China. It omitted discussion of cultural bias impacts in this regard. At the same time, the study did not discuss whether the results apply to areas with lower awareness of acupuncture, nor did it analyze the potential impact of cultural differences on the efficacy or treatment adherence. This hinders the conclusion of universality verification. Country-based subgroup or sensitivity analyses for efficacy heterogeneity are advised.

Insufficient Control of Confounding Factors

The subgroup analysis of the study was only based on intervention types and adherence to drug guidelines, without in-depth exploration of other potential factors such as treatment duration, patient age, and migraine subtypes that may affect efficacy. In addition, the heterogeneity of acupuncture techniques was not adequately addressed. There were significant differences in acupoint selection, stimulation parameters, and treatment frequency across different studies, which may significantly affect efficacy.³ Expanding subgroup analysis to include confounding factors and acupuncture techniques is recommended to enhance result comparability and reliability.

Despite the shortcomings in risk assessment, confounding bias, and subgroup analysis, this study provided evidence for the potential advantages of acupuncture in migraine prophylaxis and treatment. We look forward to more rigorous and high-quality studies in the future to verify the application value of acupuncture in the field of pain management.