Background There is much interest in ultra-short alcohol screening in primary care that may support brief alcohol interventions. Brief screening consisting of one or two questions might be used alone or in combination with longer tests as recommended by the Primary Care Service Framework. Aim To investigate whether a simple one and two question screening might prove an accurate and acceptable screening method in primary care. Design and setting A systematic literature search, critical appraisal and meta-analysis were conducted. Method A comprehensive search identified 61 analyses of single questions to detect alcohol problems including 17 that took place in primary care, using a robust interview standard. Despite focusing alcohol-use disorder in primary care settings, heterogeneity remained high, therefore random effects and bivariate meta-analyses were used. Results After adjustments, diagnostic accuracy of a single-question approach was given by a sensitivity of 54.5% (95% CI = 43.0% to 65.5%) and a specificity of 87.3% (95% CI = 81.5% to 91.5%) using meta-analytic weighting. Two questions had a sensitivity of 87.2% (95% CI = 69.9% to 97.7%) and specificity of 79.8% (95% CI = 75.7% to 83.6%). Looking at each question individually, the most successful single question was a modification of the Single Alcohol Screening Question (SASQ) namely, 'How often do you have six or more drinks on one occasion?'. The optimal approach appears to be two questions followed by the CAGE questionnaire, which achieved an overall accuracy of 90.9% and required only 3.3 questions per attendee. Conclusion Two brief questions can be used as an initial screen for alcohol problems but only when combined with a second-step screen. A brief alcohol intervention should be considered in those individuals who answer positively on both steps.