BACKGROUND: Although innovative pharmacological therapies for migraine prevention are now available, they may not be suitable or effective for all patients due to concerns about tolerability and the varying complexity of the underlying condition. This study systematically reviewed and meta-analyzed acupuncture's effects on migraine prophylaxis compared to standard medical care, focusing on study heterogeneity and issues related to sham interventions. METHODS: Following the PRISMA guidelines and using the PICO model, the study searched PubMed, Scopus, CNKI, and VIP database from December 1965 to September 2024. Studies evaluating acupuncture's clinical efficacy for migraine prophylaxis, including clinical trials, observational studies, case series, and case reports, were considered. An additional search was conducted on the clinicaltrials.gov database from the beginning of indexing up to September 2024 to include ongoing studies. Quality control and bias assessment were performed. Primary outcomes focused on acupuncture's efficacy and safety versus pharmacological treatments in reducing migraine frequency and intensity. The impact on patients' quality of life was also evaluated. RESULTS: At the end of the selection process, 15 studies were eligible. Acupuncture showed no statistically significant difference as a prophylactic treatment for migraine in reducing the frequency of migraine days or pain intensity but did reduce the use of analgesics while improving patients' quality of life. CONCLUSION: Current evidence supports acupuncture as an adjunctive therapy in migraine prophylaxis, but challenges such as protocol heterogeneity, dropout biases, the complexities of sham-controlled trials, and the lack of comparison data with newer innovative treatments not yet considered warrant further research.