Primary insomnia affects between 10% and 30% of adults worldwide and represents one of the most frequent reasons for medical consultation related to mental health and quality of life. Available pharmacologic options — benzodiazepines, Z-drug receptor modulators, and sedating antihistamines — carry risks of dependence, tolerance, and residual daytime effects. A new network meta-analysis published in Frontiers in Neurology brought together 80 randomized clinical trials and 7,791 patients to systematically compare different acupuncture modalities with each other and with conventional medication. The results position medical acupuncture as a therapeutic alternative with better SUCRA ranking performance compared with isolated pharmacologic treatment for sleep quality.
SCALE OF THE NETWORK META-ANALYSIS
How the study was conducted
The researchers performed a systematic search in multiple international databases, selecting randomized clinical trials that evaluated acupuncture modalities for primary insomnia. The main outcome was sleep quality measured by the PSQI (Pittsburgh Sleep Quality Index), a scale validated internationally with score from 0 to 21, in which higher scores indicate worse sleep quality. Secondary outcomes included anxiety scales, depression scales, and adverse-event profile.
Main results by modality
For PSQI score reduction — the primary sleep-quality outcome — three modalities were associated with better SUCRA ranking performance compared with conventional medication: abdominal acupuncture, standard acupuncture, and catgut embedding technique (implantation of absorbable suture in acupoints). “Warm” acupuncture — which combines needling with moxibustion — demonstrated advantage over traditional acupuncture specifically in long-term outcomes, suggesting that the thermal component may potentiate the maintenance of effects.
MODALITIES WITH BEST PERFORMANCE
Benefits on comorbid anxiety and depression
A clinically relevant finding was that both abdominal acupuncture and standard acupuncture reduced anxiety scores significantly more than sham — and not only than the conventional medication group. This is relevant because primary insomnia rarely occurs in isolation: anxiety is the most frequent comorbidity, present in about 40% to 60% of patients with chronic insomnia. The capacity of an intervention to act simultaneously on sleep quality and anxiety represents an important therapeutic differential in clinical practice.
Limitations and considerations
The authors acknowledge heterogeneity in the duration of treatments and in the acupoint protocols among the included studies. Most trials were conducted in China, which may limit generalization to Western populations with different comorbidity profiles and therapeutic expectations. In addition, studies varied regarding the post-treatment follow-up period, hampering precise comparisons of durability of effects between modalities. Even so, the robustness of the Bayesian methodology and the large number of participants confer credibility to the general conclusions.
Frequently Asked Questions
Abdominal acupuncture is a system developed by the Chinese physician Bo Zhiyun in the 1970s-1980s, which uses exclusively acupoints located on the abdomen to treat systemic conditions, including sleep disorders. Insertion is generally superficial and painless. Standard acupuncture uses a broader set of acupoints distributed throughout the body, selected according to diagnosis and clinical protocol.
In many cases of primary insomnia, medical acupuncture may function as a non-pharmacologic first-line alternative or complement to cognitive-behavioral approaches. The decision to replace, reduce, or maintain medication should be individualized by the physician, considering the severity of insomnia, duration of medication use, comorbidities, and response to acupuncture treatment. In severe insomnia or insomnia associated with psychiatric disorders, the combined approach is usually more appropriate.
The studies included in the meta-analysis varied between 4 and 12 weeks of treatment, with frequency of 2 to 3 sessions per week. The response is usually progressive — initial improvements in time to fall asleep and in nocturnal awakenings tend to appear after 3 to 4 sessions, with consolidation over 8 to 12 weeks. The individualized protocol should be defined by the medical acupuncturist according to the patient’s clinical profile.
Founded in 1989 by physicians trained at the University of São Paulo (USP) and specialized in China, CEIMEC is a Brazilian national reference in the teaching and practice of medical acupuncture. With more than 3,000 physicians trained over 35 years, it collaborates with HC-FMUSP and is recognized by the Brazilian Medical College of Acupuncture (CMBA/AMB).
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