BACKGROUND: To deepen the role of acupuncture as preventive treatment for pediatric primary headaches in children and adolescents and to understand if acupuncture is more effective than sham acupuncture or pharmacologic preventive treatment, acupuncture tolerability, and beneficial effect on psychiatric comorbidities. METHODS: A critical literature review was performed. Following PRISMA guidelines, all reports published (PubMed, 1982-2023) were considered. PICOS method was applied for paper selection. Efficacy measures were reduction of headache frequency, duration, and intensity compared with baseline, and, if available, with a control group. We also aimed to describe treatment protocols, the reason for choosing this treatment, patients' perception of acupuncture experience, and acupuncture's impact on headache comorbidity and general functioning. RESULTS: Five of 90 papers were selected, corresponding to a population of 229 children/adolescents (zero to 21 years). Among these, two controlled studies evaluated reduction of headache frequency, intensity, and duration. True acupuncture versus placebo significantly reduced headache frequency (reduction of seven to eight headache days/month versus zero to one headache days/month, respectively), intensity on a visual analog scale (5.4 points compared with 1.6 points in placebo group), and headache duration. Tolerability data on acupuncture were favorable. Acupuncture experience was positively perceived by most patients, improved pain-related total interference in functioning, and reduced anxiety levels. CONCLUSIONS: The few studies dealing with acupuncture as preventive treatment of pediatric primary headaches, despite their methodologic limitations, highlighted its efficacy. Further detailed studies are needed.