Procedural interventions for chronic migraine: an umbrella review intervention-specific evidence map

To synthesize and map intervention-specific evidence on the efficacy, clinical relevance, and safety of procedural interventions for chronic migraine (CM).

We conducted a PROSPERO-registered umbrella review in accordance with PRISMA 2020 and methodological guidance for umbrella reviews. Eligible systematic reviews evaluated onabotulinumtoxinA, greater occipital nerve block (GONB), other peripheral nerve blocks and percutaneous procedures, acupuncture, implanted occipital nerve stimulation (ONS), or surgical interventions. Evidence concerning the addition of CGRP-targeted monoclonal antibody therapy to ongoing onabotulinumtoxinA treatment was retained separately as contextual evidence on adjunctive pharmacotherapy and was not classified as a procedural intervention. Methodological quality was assessed using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2), certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE), and primary-study overlap using the corrected covered area (CCA). Evidence was synthesized separately by intervention, outcome, comparator, and follow-up period. Pooled estimates from different systematic reviews were not statistically combined, and clinically heterogeneous evidence was summarized narratively.

Seventeen reviews were included, of which 12 contained at least one meta-analysis. The strength and maturity of evidence varied substantially across interventions. OnabotulinumtoxinA had the most established evidence base and the clearest role in CM prevention. For GONB, low-certainty evidence from clinically comparable randomized trials suggested a possible short-term reduction in headache day and headache severity, although sustained benefit remains uncertain. Evidence for combined onabotulinumtoxinA-CGRP monoclonal antibody therapy was derived predominantly from uncontrolled observational cohorts and should therefore be considered preliminary. Implanted ONS showed possible benefit in selected patients with refractory CM, but evidence was limited by small study numbers, imprecision, heterogeneous outcomes, and device- or procedure-related risks. Evidence for acupuncture, other peripheral nerve blocks, percutaneous procedures, and surgical interventions was limited by clinical heterogeneity, indirectness, uncontrolled study designs, or uncertain applicability specifically to CM. TRAEs profiles differed substantially among intervention categories and were therefore not pooled across procedures. Most intervention-outcome evidence was rated as low or very low certainty.

Procedural interventions for CM should not be interpreted as a homogeneous therapeutic class. OnabotulinumtoxinA is supported by the most mature evidence and established clinical positioning, whereas GONB may provide a short-term, protocol-specific benefit with low certainty. Evidence for other procedures remains preliminary, heterogeneous, or restricted to selected patient populations. Clinical interpretation and treatment selection should therefore be intervention-specific and patient-specific. Future research should prioritize standardized diagnostic criteria, treatment protocols, comparators, clinically meaningful outcomes, TRAEs reporting, and longer-term follow-up. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261415558, identifier: CRD420261415558.