STUDY DESIGN: A systematic review of randomized clinical trials (RCTs). OBJECTIVES: To assess the effectiveness of physiotherapy and spinal manipulation in patients with tension-type headache. METHODS: This is an update of a review published in 2004. Literature was searched in PubMed, CINAHL and Cochrane. Only RCTs of physiotherapy and manipulations in adults (greater than 18 years) were included. Two reviewers independently assessed the methodological quality of the retrieved studies, using the Delphi list, and extracted relevant data. Where possible, results are expressed as effect estimates. Analysis was performed based on 'levels of evidence'. RESULTS: Twelve studies met the inclusion criteria: 8 studies included in the original review and 4 new studies. A broad range of interventions was used, such as manipulation, physical training, physiotherapy, massage, relaxation therapy, and acupuncture. Two studies had a low risk of bias, both of which evaluated manipulation compared to placebo (placebo laser) or medication. There were no significant differences between the therapies. A specific exercise programme might be effective but evidence for this was limited (only 1 study). CONCLUSION: On the basis of available evidence, it is possible to draw firm conclusions about the effectiveness of manipulation and physiotherapy for the treatment of tension-type headache, but a specific exercise programme shows potential.

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