Comparative effectiveness and safety of acupuncture treatments for primary insomnia: a systematic review and network meta-analysis of randomized trial
Fang et al. · Frontiers in Neurology · 2026
Evidence Level
STRONGOBJECTIVE
Compare the efficacy and safety of nine different acupuncture modalities for primary insomnia using Bayesian network meta-analysis
WHO
7,791 patients with primary insomnia, 80 studies from 2015-2025, all conducted in Asia
DURATION
Short-term (4 weeks) and long-term (≥4 weeks) effects assessed
POINTS
Multiple combinations including GV-20, HT-7, SP-6, EX-HN1, EX-HN17, PC-6, depending on modality
🔬 Study Design
Traditional acupuncture
n=3465
Conventional acupuncture with traditional needling
Abdominal acupuncture
n=144
Specific technique focused on abdominal points
Electroacupuncture
n=471
Electrical stimulation of points
Catgut embedding
n=588
Implantation of catgut at acupuncture points
Other modalities
n=3123
Press needle, warm acupuncture, fire needle, scalp acupuncture, etc.
📊 Results in numbers
PSQI reduction (short-term) - abdominal acupuncture vs medication
PSQI reduction (long-term) - abdominal acupuncture vs medication
Anxiety improvement - acupuncture vs sham
Clinical efficacy rate - acupuncture vs medication
Overall adverse-event rate
Percentage highlights
📊 Outcome Comparison
Pittsburgh Sleep Quality Index (PSQI) Reduction
This large study compared different types of acupuncture to treat insomnia and found that abdominal acupuncture may be the most effective for improving sleep quality. Acupuncture proved to be safe, with few side effects, and more effective than conventional medications. The results suggest that different acupuncture techniques can benefit specific aspects of insomnia.
Article summary
Plain-language narrative summary
This broad systematic review and network meta-analysis represents the most comprehensive study ever conducted on different acupuncture modalities for primary insomnia. The researchers analyzed 80 randomized controlled trials involving 7,791 patients, all conducted in Asia between 2015 and 2025. The study used advanced Bayesian methodology to simultaneously compare nine different acupuncture techniques: conventional acupuncture, abdominal acupuncture, electroacupuncture, catgut embedding, press needle, scalp acupuncture, wrist-ankle needle, warm acupuncture, and fire needle. The results revealed that abdominal acupuncture demonstrated potentially superior advantages for improving both short-term and long-term Pittsburgh Sleep Quality Index (PSQI) scores.
Compared with conventional medications, abdominal acupuncture significantly reduced PSQI scores by 3.73 points in the short term and 5.46 points in the long term. The technique also proved effective in reducing anxiety symptoms. Catgut embedding, a technique that involves implanting absorbable threads at acupuncture points, was particularly effective in reducing depression scores and traditional Chinese medicine syndrome. Electroacupuncture stood out for improving overall clinical efficacy rates.
Regarding safety, the study identified an overall adverse-event rate of only 5.59%, the majority being local and transient reactions such as pain at the insertion site, hematomas, and dizziness. Wrist-ankle needle showed the best safety profile according to SUCRA analysis. It is important to note that, although different modalities showed specific advantages, no significant differences were found in relative effectiveness between the different acupuncture techniques when directly compared with each other. The study has important limitations including high methodological heterogeneity among studies, variations in acupuncture protocols even within the same technique, and possible publication bias.
In addition, the impossibility of complete blinding in acupuncture procedures remains a methodological challenge. The findings provide robust evidence that acupuncture is effective and safe for primary insomnia, offering a valuable alternative to conventional medications, which often cause dependence and side effects. Clinical implications suggest that different acupuncture modalities can be selected based on patients' specific symptoms and therapeutic goals.
Strengths
- 1Largest and most comprehensive network meta-analysis on acupuncture for insomnia
- 2Rigorous Bayesian methodology allowing simultaneous comparison of multiple interventions
- 3Large sample size with 7,791 participants
- 4Assessment of multiple outcomes including sleep quality, anxiety, depression, and safety
- 5Analysis of short- and long-term effects
Limitations
- 1Significant methodological heterogeneity among studies
- 2Variations in acupuncture protocols even within the same modality
- 3Possible publication bias detected
- 4Impossibility of complete blinding in acupuncture
- 5Studies limited to Asian publications, potential geographic bias
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
Primary insomnia is one of the most frequent complaints at the pain and rehabilitation clinic, and dependence on benzodiazepines and non-benzodiazepine hypnotics remains a concrete problem in daily practice. This network meta-analysis with 7,791 patients and nine acupuncture modalities compared simultaneously offers an actionable clinical map: it is no longer a question of asking whether acupuncture works for insomnia, but which technique to prioritize according to the symptom profile. Abdominal acupuncture emerged as a modality of note for PSQI improvement, both in the short and long term, while catgut embedding showed advantage for the depressive component and electroacupuncture for overall clinical efficacy. This level of granularity allows the physician to align the technical choice to the patient's presentation — especially in populations in whom hypnotics are contraindicated, such as polymedicated older adults, pregnant patients, and patients with apnea under investigation.
▸ Notable Findings
The 5.46-point reduction in PSQI by abdominal acupuncture in the long term versus conventional medication is clinically expressive — the minimum clinically important difference for the PSQI is between 2.5 and 3 points, so we are talking about a magnitude consistently above the threshold of practical relevance. The effect on anxiety with an SMD of -2.00 against sham is particularly noteworthy, because primary insomnia and generalized anxiety disorder coexist in a significant portion of patients, and any intervention that reaches both simultaneously reduces therapeutic complexity. The overall adverse-event rate of only 5.59%, predominantly transient local reactions, positions acupuncture favorably against the risk profile of classic hypnotics. The finding that the modalities do not differ significantly from each other in direct comparisons reinforces that the underlying mechanism — modulation of GABAergic and serotonergic pathways, in addition to regulation of the HPA axis — is shared regardless of the technique of entry.
▸ From My Experience
In my practice at the pain clinic, insomnia rarely comes alone — it orbits chronic pain, fibromyalgia, or anxiety disorders, and pharmacologic management is often already at the limit of tolerability. I have incorporated electroacupuncture as a first choice in these combined cases, observing a measurable response in sleep quality generally from the third or fourth session, with stabilization between the eighth and twelfth session. For patients with a predominant anxious component, I add points from the heart and pericardium meridians to the conventional routine, which converges with the marked anti-anxiety effect reported here. Catgut embedding has a real niche in patients with poor adherence to weekly sessions — the biweekly or monthly interval is operationally advantageous. I do not indicate acupuncture as monotherapy when there is suspicion of untreated obstructive apnea or severe paradoxical insomnia; in those cases, cognitive behavioral therapy for insomnia comes first. The patient profile that benefits most in my experience is the one with maintenance insomnia, background anxiety, and who has already presented dependence or intolerance to benzodiazepines.
Full original article
Read the full scientific study
Frontiers in Neurology · 2026
DOI: 10.3389/fneur.2026.1750474
Access original articleScientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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