Efficacy and safety of different acupuncture-related therapies for primary trigeminal neuralgia: a systematic review and network meta-analysis

BACKGROUND: Primary trigeminal neuralgia (PTN) is a debilitating neuropathic pain disorder with limited long-term treatment options. Although acupuncture is widely used, the comparative effectiveness of different acupuncture modalities remains unclear. OBJECTIVE: To compare the efficacy and safety of various acupuncture therapies for PTN using a network meta-analysis (NMA). METHODS: Randomized controlled trials were identified through a systematic search of seven databases from database inception to 2 March 2026. Outcomes included total effective rate (TER), visual analogue scale (VAS), attack frequency (AF), traditional Chinese medicine syndrome score (TCMSS), and adverse events (AEs). A network meta-analysis was conducted, and treatments were ranked using SUCRA. RESULTS: This network meta-analysis included 58 randomized controlled trials. The results showed that bloodletting therapy was identified as a potentially effective intervention for improving TER (RR = 2.00, 95% CI: 1.15-3.47; SUCRA = 95.6%; CINeMA: low certainty) and reducing VAS scores (MD = 0.07, 95% CI: 0.01-0.61; SUCRA = 87.4%; CINeMA: very low certainty). In contrast, acupuncture combined with conventional Western medicine performed better in reducing AF (MD = 0.05, 95% CI: 0.02-0.14; SUCRA = 100%; CINeMA: very low certainty), improving TCMSS (SMD = 0.15, 95% CI: 0.07-0.34; SUCRA = 90.7%; CINeMA: very low certainty), and decreasing the risk of AEs (OR=0.18, 95% CI: 0.12-0.28; SUCRA = 73.8%; CINeMA: moderate certainty). CONCLUSIONS: Different acupuncture modalities may offer distinct therapeutic benefits for PTN. Bloodletting therapy showed potential advantages in improving TER and reducing VAS, whereas acupuncture combined with conventional Western medicine appeared to perform better in reducing AF, improving TCMSS, and lowering the risk of AEs. However, these findings should be interpreted cautiously because of moderate-to-high heterogeneity across some outcomes and the generally low certainty of the evidence. Further large-scale, multicenter, high-quality randomized controlled trials are warranted to confirm these findings. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/prospero/, PROSPERO (CRD420261339021).