# Critical limitations compromise the conclusions of a recent meta-analysis regarding spinal manipulation and migraine: a commentary

## TL;DR

This commentary points out major methodological flaws in a recent meta-analysis on spinal manipulation for migraines, questioning its reliability and suggesting caution in using its conclusions.

## Contribution

The paper identifies and explains critical methodological shortcomings in a prior meta-analysis on spinal manipulation therapy for migraines.

## Key findings

- The search strategy and database coverage were incomplete, missing 1845 articles.
- The analysis conflated mild adverse effects with serious ones and downplayed potential benefits.
- The meta-analysis's conclusions are unreliable due to methodological flaws.

## Abstract

A recent meta-analysis by Posadzki et al. synthesized randomized controlled trials to evaluate the effectiveness and safety of spinal manipulative therapy (SMT) for migraines. Considering Systematic Reviews recognizes several methodological guidelines and reporting standards, our Letter highlights deviations from best practice methodologies.

We detail issues with the search strategy, application of selection criteria, inclusion of data, and outcome reporting and analysis. We partially replicated the authors’ search across three of their seven databases, which identified 1845 more articles than they reported. Finally, the authors’ interpretations appear to conflate mild and transient adverse effects with serious ones and minimize potentially meaningful benefits of SMT.

The methodological limitations in the meta-analysis by Posadzki et al. raise concerns about its reliability and reproducibility. Accordingly, we advise against relying on this study to guide clinical decision-making. Clinicians, patients, and stakeholders should interpret its conclusions cautiously when evaluating the appropriateness of SMT for migraine management.

The online version contains supplementary material available at 10.1186/s13643-025-02849-5.