Original Article

Volume: 2 | Issue: 3 | Published: Aug 15, 2026 | Pages: 388 - 411 | DOI: 10.24911/amem.15-2790

Annals of Middle Eastern Medicine

Adnan Ahmed Badahdah et al. Annals of Middle Eastern Medicine. 2026;2(3):388-411

DOI: 10.24911/amem.15-2790

ORIGINAL ARTICLE

Physical therapy in tension-type headache: a systematic review of randomized controlled trials

Adnan Ahmed Badahdah1, Majed Hassan Alahmadi2, Gharam Abdulaziz Alahmadi3*, Mohamad Bassel Dahha3, Amal Abdullah Alzahrani4, Ahad A. Alkenani5, Yazeed Abdulrahman Alqahtani6, Khalid M. Alrashidi7, Nourah Ali Alqhtani8, Amjad Adel Alosaimi9, Bashayer N. Alkorbi10

Correspondence to: Gharam Abdulaziz Alahmadi

*College of Medicine, Ibn Sina National College, Jeddah, Saudi Arabia.

Email: gharamalahmadi57@gmail.com

Full list of author information is available at the end of the article.

Received: 03 April 2026 | Revised (1): 31 May 2026| Accepted: 03 June 2026

© Adnan Ahmed Badahdah, Majed Hassan Alahmadi, Gharam Abdulaziz Alahmadi, Mohamad Bassel Dahha, Amal Abdullah Alzahrani, Ahad A. Alkenani, Yazeed Abdulrahman Alqahtani, Khalid M. Alrashidi, Nourah Ali Alqhtani, Amjad Adel Alosaimi, Bashayer N. Alkorbi
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ABSTRACT

Background:

Tension-type headache (TTH) is the most prevalent neurological disorder globally, affecting over 2 billion individuals and posing a substantial public health and socioeconomic burden. Although pharmacological treatments, such as non-steroidal anti-inflammatory drugs, offer symptomatic relief, concerns regarding long-term efficacy and medication overuse have driven interest in physical therapy as an alternative or adjunctive intervention.

Methods:

In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search from inception to December 2024 was conducted in the following electronic databases: PubMed, Google Scholar, Web of Science, the Cochrane Library, and DOAJ. Randomized controlled trials investigating the effect of physiotherapy on TTH were included.

Results:

Fifty-one randomized controlled trials involving 3,404 participants were included in this review. The studies investigated various physical therapy interventions, including manual therapy, therapeutic exercise, and multimodal approaches. The majority of the included studies demonstrated statistically significant improvements in headache intensity, frequency, and duration compared to control groups. Adverse events, when reported, were minor and transient. No serious complications were associated with the physical therapy interventions.

Conclusion:

Physical therapy interventions can be safe with minimal adverse effects in managing patients with TTH. Various physical therapy interventions are effective in reducing pain intensity, frequency, and duration of TTH, both chronic and episodic. However, the lack of long-term outcome data highlights the need for future high-quality randomized controlled trials with extended follow-up.

Keywords:

Headache, tension-type headache, physical therapy, physiotherapy, manual therapy.

Introduction

Tension-type headache (TTH) is the most prevalent neurological disorder worldwide, affecting over 2 billion individuals [1]. It ranks as the second leading cause of chronic disease and disability, underscoring its significant public health burden [2,3]. Beyond its clinical impact, TTH imposes considerable socioeconomic consequences, as it contributes to reducing work efficiency due to absenteeism and presenteeism, ultimately diminishing productivity [2].

Epidemiological data from the Global Burden of Disease study confirm the widespread prevalence of headache disorders. However, methodological discrepancies across studies have resulted in substantial variability in prevalence estimates, creating uncertainty regarding regional differences and trends over time [3]. Given the high global burden of TTH, understanding its underlying pathophysiology and optimizing treatment approaches are critical to improving patient outcomes.

TTH is a multifactorial disorder involving cranial and cervical muscle tension, psychological stress, and central sensitization [4]. Among individuals with chronic headache, sleep disturbances such as insomnia are frequently reported, with studies suggesting a bidirectional relationship between sleep dysfunction and headache severity [5]. The complex interplay of musculoskeletal, neurological, and behavioral factors in TTH necessitates a comprehensive approach to treatment that goes beyond symptomatic relief.

The primary pharmacological treatment for TTH involves simple analgesics and non-steroidal anti-inflammatory drugs, with ibuprofen (400 mg) and aspirin (1,000 mg) being widely recommended due to their efficacy and safety profile. However, reliance on pharmacotherapy raises concerns regarding medication overuse headache, potential side effects, and limited effectiveness in chronic cases. Consequently, there has been increasing interest in non-pharmacological interventions, particularly physical therapy, as an alternative or adjunct to pharmacological management.

Unlike pharmacological treatments that primarily provide temporary symptomatic relief, physical therapy directly addresses the musculoskeletal dysfunctions contributing to TTH. Manual therapy techniques, such as trigger point release therapy, suboccipital inhibitory pressure, and instrument-assisted soft tissue mobilization, aim to reduce muscle tension, restore cervical mobility, and alleviate myofascial pain. Acupuncture-based therapies, including dry needling, target neuromuscular sensitization and pain modulation. In addition, structured exercise programs, such as aerobic exercise and deep breathing exercises, enhance muscular flexibility and reduce physiological stress responses.

Despite promising findings, the efficacy of physical therapy for TTH remains uncertain due to variability in treatment protocols, differences in outcome measures, and a lack of long-term follow-up studies. Furthermore, comparative analyses assessing the relative effectiveness of different physical therapy techniques are limited. Addressing these gaps is essential to establishing evidence-based guidelines for integrating physical therapy into standard TTH management.

In this study, we aim to evaluate the effectiveness of physical therapy in reducing headache intensity, frequency, and duration in adults diagnosed with TTH.

Methods

Search strategy

This review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA 2020) Page et al. [6]. A systematic search was performed in several databases, including PubMed, Google Scholar, Web of Science, the Cochrane Library, and DOAJ, using a combination of keywords (tension-type headache OR tension headache OR TTH) AND (physical therapy OR physiotherapy OR physical treatment OR physical exercises OR physical therapy interventions OR physical therapy modalities). This review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO; registration ID: CRD42024561923).

Study selection and eligibility criteria

Two independent reviewers performed a literature search in several databases from inception to December 2024. The search was limited to the English language, and only studies with primary data were included. The combination of keywords used was: (tension-type headache OR tension headache OR TTH) AND (physical therapy OR physiotherapy OR physical treatment OR physical exercises OR physical therapy interventions OR physical therapy modalities). The studies have been evaluated using a two-level assessment approach. Level 1 screening included titles and abstracts of retrieved records. The complete text of all potentially eligible citations was obtained and reviewed for final eligibility. All studies were screened based on the specified eligibility criteria outlined below. Studies that met the following criteria were included in this meta-analysis: (i) studies published without time frame limitations; (ii) studies in the English language; (iii) the review included studies with adult patients above 18 who were diagnosed with TTH; and (iv) the included studies reported outcomes of interest relevant to the clinical questions and included randomized controlled trials (RCTs) only.

Data extraction

Two independent reviewers extracted data from acceptable studies, including authors, study design, mean age, sex, sample size, number of sessions, and follow-up period, into a tested Excel spreadsheet. The two examiners cross-checked and verified the extraction sheet to eliminate errors and ensure the data’s integrity.

Bias assessment

We performed a quality assessment for 51 studies. Following the ROB-2 Quality Assessment Tool guidelines Sterne et al. [7], 23 studies were considered to have good quality (low risk of bias). However, 28 studies were considered to have moderate quality (moderate risk of bias) due to some concerns in different domains, like the randomization process, deviations from the intended intervention, and missing data.

Results

Study selection and characteristics

The initial search yielded 1,923 potential articles. After screening titles and abstracts, 1,630 full-text articles were assessed for eligibility. Ultimately, 51 randomized controlled trials met the inclusion criteria (Figure 1). These studies included a total of 3,404 participants, aged between 20 and 55 years (Table 1). The sample consisted predominantly of females (approximately 70% of participants) diagnosed with either chronic tension-type headache or episodic tension-type headache (Table 2).

Figure 1. PRISMA flow diagram of study selection for the included studies in the systematic review.

Risk of bias assessment

The methodological quality of the included studies varied. Random sequence generation and allocation concealment were adequately reported in approximately 60% of the trials. Blinding of participants and therapists was a common challenge due to the nature of physical therapy interventions; however, blinding of outcome assessors was maintained in the majority of high-quality studies (Figure 2).

Efficacy of interventions

The included studies utilized a wide range of physical therapy interventions. Manual therapy (including suboccipital release and spinal manipulation) was the most common modality, appearing in 15 studies, followed by therapeutic exercises (craniocervical strengthening and aerobic training) in 12 studies. Other interventions included acupuncture, dry needling, and electrotherapy. Multimodal physical therapy programs, combining manual techniques with exercise, were evaluated in 14 studies. Across the 51 studies, physical therapy consistently resulted in significant reductions in headache frequency, intensity, and duration compared to control or placebo groups. Manual therapy techniques showed immediate improvements in pain pressure thresholds, while therapeutic exercises demonstrated long-term benefits, particularly in reducing headache frequency (Table 3).

Adverse events

Safety data were explicitly reported in 38 of the 51 studies. Generally, physical therapy interventions were well-tolerated. Reported adverse events were mild and transient, including post-treatment muscle soreness, temporary fatigue, and minor bruising (primarily associated with dry needling). No serious or life-threatening adverse events were recorded in any of the included trials (Table 4).

Table 1. The studies’ characteristics.

Author name, year, country Study design  Sample size Age Sex, Male N (%) Sex, Female N (%) BMI (kg/m 2 )
Group 1 (Treatment) Group 2 (Control) Total Group 1 (Treatment) Group 2 (Control) Total Group 1 (Treatment) Group 2 (Control) Total Group 1 (Treatment) Group 2 (Control) Total Group 1 (Treatment) Group 2 (Control) Total
Damapong et al. [8] RCT 30 30 60 N/M N/M 49.75+-10.93 4 1 5 26 29 55 N/M N/M N/M
Gildir et al. [9] Double-blind, parallel-group RCT 80 80 160 36.7 ± 7.6 years  36.0 ± 8.3 years N/M N/M N/M N/M 41 (51.3%) 44 (55%) 85 N/M N/M N/M
Endres et al. [10] Multicenter, patient- and observer-blinded RCT 209  200  409 39.2 ± 11.4 years  38.9 ± 12.2 years N/M N/M N/M N/M 163 (78%) 158 (79%) 321 24 (21–27) 24 (22–26) N\M
Mohamadi et al. [11] RCT 13 13 26 39 ± 11 years 38 ± 9 years N/M 2  3  5  11  10  21  N/M N/M N/M
Soderberg et al. [12] RCT 27 28. and Group3: 25 80 40.5 ± 10.4 years 43.1 ± 8.8 years and Group3: 40.9 ± 8.3 years N/M 6 7 and Group3: 6 19 21 21 and Group3:19 61 N/M N/M N/M
Kwon and Yoon [13] RCT 11 11 and Group3: 11 33 40.73 ± 7.82 years 49.27 ± 11.37 years and Group3: 41.82 ± 7.50 years N/M 5 6 and Group3: 5 16 6 5 and Group3: 6 17 N/M N/M N/M
Aslam et al. [14] RCT 16 15 31 35.81 ± 9.30 years 30.73 ± 7.99 years N/M N/M N/M N/M N/M N/M N/M 24.11 ± 3.49 22.43 ± 3.36 N/M
Espí-López et al. 15] Factorial, single-blinded, RCT 19 19 76 (19 per group across four groups) Mean 43.74 years (SD 13.73)  Mean 41.58 years (SD 10.02) 39.9 years (SD 10.9) 2 8 14 17 11 28 N/M N/M N/M
Kamali et al. [16] Parallel single-blind RCT 20 20 40 Mean 37.45 years (SD 12.57)  Mean 33.70 years (SD 9.94) N/M 4 1 5 16 19 35 N/M  N/M  N/M 
Saad et al. [17] Single-blind RCT 15 15 30 Mean 36.67 years (SD 4.18)  Mean 33.73 years (SD 3.26) N/M N/M N/M N/M N/M N/M N/M Mean 24.31 kg/m² (SD 1.46)  Mean 24.65 kg/m² (SD 1.04) N/M
Espí-López et al. [18] RCT 19 19 76 (62 women, 14 men) 39.9 ± 10.9 years N/M N/M N/M N/M 14 N/M N/M 62 N/M N/M N/M
Ferragut-Garcías et al. [19] Double-blind, placebo-based RCT Group A (Placebo): 24Group B (Soft tissue): 23 Group C (Neural mobilization): 25Group D (Combined): 25 97 Group A: 40.5 ± 12.0 yearsGroup B: 38.1 ± 10.9 years Group C: 39.4 ± 11.0 yearsGroup D: 40.8 ± 12.1 years 39.7 ± 11.5 years Group A: 4 (16.7%)Group B: 6 (26.0%) Group C: 5 (20.0%)Group D: 4 (16.0%) 19 (19.6%) Group A: 20 (83.3%)Group B: 17 (74.0%) Group C: 20 (80.0%)Group D: 21 (84.0%) 78 (80.4%) Group A: 25.3 ± 3.0 kg/m²Group B: 24.7 ± 3.4 kg/m² Group C: 25.1 ± 3.3 kg/m²Group D: 24.9 ± 3.0 kg/m² 25.0 ± 3.2 kg/m²
Ajimsha [20] Single-blinded RCT Group A (DT-MFR): 22 Group B (IDT-MFR): 22Group C (Control): 12 56 Group A: 43.7 ± 5.6 years Group B: 44.7 ± 5.2 yearsGroup C: 43.0 ± 5.4 years 43.8 ± 5.4 years Group A: 7  Group B: 8 Group C: 5  20  Group A: 15  Group B: 14 Group C: 7  36  Group A: 24.7 ± 5.9 kg/m² Group B: 24.8 ± 6.2 kg/m²Group C: 24.2 ± 5.0 kg/m² 24.6 ± 5.7 kg/m²
Castien et al. [21] Pragmatic, multicentre, RCTclinical trial  41  41  82  20–63 20–59 N/M N/M N/M 9 N/M N/M 32 N/M N/M N/M
Hosseinifar et al. [22] RCT 15  15  30  25.06 ± 7.64 29.33 ± 11.63 N/M N/M N/M N/M 15 15 30 N/M N/M N/M
Gopichandran et al. [23] Prospective RCT 84  85  169  44.21 ± 10.7  46.167 ± 11.12 N/M 39 (46.5) 34 (40) N/M 45 (53.5) 51 (60) N/M N/M N/M N/M
Shafiq et al. [24] RCT 15 15 30 mean age: 20.27 ± 1.53 years  mean age: 21.27 ± 1.79years  N/M 5 6 11 10 9 19 N/M N/M N/M
Pérez-Llanes et al. [25] RCT 13 12 25 43.3 years 46.2 years N/M 3 1 4 10 11 21 Mean BMI: 24.7 kg/m2 Mean BMI: 26.3 kg/m2 N/M
Cabanillas-Barea et al. [26] RCT 43 43 86 37.25 years (±15.41) 39.49 years (±16.26) 38.35 years (±15.78) 12 12 24 31 31 62 N/M N/M N/M
Monti-Ballano et al. [27] Single-blinded RCT  16 16 32 mean age 31.75 ± 10.75 years  mean age 41.44 ± 14.68 years  mean age 39.09 ± 12.88 years  N/M N/M 8 N/M N/M 24 N/M N/M N/M
Álvarez-Melcón et al. [23] RCT 76 76 152 mean age 20.23 (SD ± 2.50) mean age 20.62 (SD ± 2.21) 20.42 years (SD ± 2.36) 26 42 68 50 34 84 N/M N/M N/M
Park [28] RCT 18 17 35 39.6 ± 15.9 years 41.0 ± 9.4 years N/M N/M N/M N/M N/M N/M N/M 23.8 ± 2.6 kg/m2 25.2 ± 4.2 kg/m2 N/M
Chatchawan et al. [29] Prospective, parallel-group RCT 36 36 72 mean age: 27.39 ± 6.73 years  mean age: 27.36 ± 9.55 years total mean age: 27.37 ±8 .37 years  10 7 17 26 29 55 22.48 ± 5.33 kg/m2 22.17 ± 7.55 kg/m2 22.33 ± 6.36 kg/m2
Choi et al. [30] RCT Temporomandibular group 14, cervical group 14 13 41 TMJT 35.00 ± 11.82 years , CMT 34.71 ± 7.50 years 42.62 ± 11.00 years N/M 15 8 23 13 5 18 N/M N/M N/M
Martín-Vera et al. [31] RCT 20 20 40 33.9 ± 12.2 years  40.1 ± 14.0 years  N/M 3 15% 5 25% 8 20% 17 85% 15 75% 32 24.4 ± 3.9 kg/m2 24.2 ± 4.2 kg/m2 N/M
Antonia (Gomez) et al. [32] RCT 62 22 84 N/M N/M Mean age: 39.76 years (Range: 18-65) N/M N/M 16 N/M N/M 68 N/M N/M N/M
Van Ettekoven and Lucas [33] RCT 38 42 81 48.3 43.4 45.85 N/M N/M N/M N/M N/M N/M N/M N/M N/M
Kanji et al. [34] RCT 17 20 37 40.7 44.3 ns 5 3 8 12 17 29 N/M N/M N/M
Madsen et al. [35] RCT 23 21 44 33 36 ns 5 6 11 18 15 33 24 24 24
Xue et al. [36] Single-blinded, sham-controlled, crossover clinical trial 20 20 40 42.6 (1.8) 41.5 (1.9) N/M 7 7 14 13 13 26 N/M N/M N/M
Moraska et al. [37] RCT 20 for massage 21 wait list , 21 for placepo 62 32.1 ± 12.0 32.1 ± 12.0 N/M N/M N/M N/M 88.2 89.5 N/M N/M N/M N/M
Rinne et al. [38] RCT 57 69 116 45.8 (8.6) 42.6 (9.7) N/M All female N/M N/M 57 69 N/M N/M N/M N/M
Karst et al. [39] RCT 34 35 69 47.9 (13.8) 48.2 (14.6) N/M 17 14 31 17 21 38 N/M N/M N/M
Torelli et al. [40] RCT 24 24 48 43.9 (24-63) 46.8 (29-59) 44.9 (24-63) 5 10 15 19 14 33 N/M N/M N/M
Bove and Nilsson 41] RCT 37 38 75 37 (22-59) 38 (20-58) 38 (20-59) 15 11 26 23 26 49 N/M N/M N/M
Hamed [42] Parallel RCT 15 for each group SOES (group A); SPTP (group B); 15 45 Group A =37.0 ± 7.1 Group B =36.6 ± 7.2 35.6 ± 4.6 N/M 5 in group A, 6 In group B 5 16 10 IN GROUPA, 9 in group B 10 29 N/M N/M N/M
Karakurum et al. [43] Randomized, double-blind study 15 15 30 28.4 ± 11.6 27.9 ± 10 N/M all females N/M N/M N/M N/M N/M N/M N/M N/M
Cabanillas-Barea et al. [44] RCT 41 41 82 37.25 (15.41) 39.39 (16.26) N/M 11 11 22 29 28 57 24.08 (2.17) 23.83 (1.70) N/M
Corum et al. [45] RCT 15 for each group (group A)and (group B); 15 45 Group A = 33.5 ± 8.2, Group B = 30.7 ± 8.0 32.5 ± 6.5 N/M Group A = 4, Group B = 3 4 11 Group A = 9, Group B = 11 8 28 Group A = 22.1 ± 2.3, Group B = 21.9 ± 2.6 23.5 ± 3.2 N/M
Sertel and Bakar [46] RCT BAT (n = 20), aerobic exercise (n = 20) 20 60 42.6 ± 9.5 for BAT group, 36.20 ± 7.86 for AE Group 39.00 ± 9.53 N/M N/M N/M N/M N/M N/M N/M 27.31 ± 5.6 for BAT group, 27.10 ± 4.6 for AE Group 25.66 ± 3.71 N/M
Kwon and Yoon [47] RCT 15 15 30 37.93 ± 10.32 38.27 ± 11.10 N/M 8 7 15 7 8 15 N/M N/M N/M
Espí-López et al. [48] Single-blinded, RCT 52 52 104 37.69 ± 10.64 40.47 ± 11.33 N/M 10 13 23 41 38 79 N/M N/M N/M
Azhdari et al. [49] Parallel design RCT 12 12 24 43.16 41.41 N/M 5 4 9 7 8 15 N/M N/M N/M
Georgoudis et al. [50] A single‐blind, prospective, multicentre, RCT 20 24 44 54.8 ± 14.7 43.0 ± 6.5 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Georgoudis et al. [51] A single-blind multicenter-RCT 20 24 44 54.8 ± 14.7 43.0 ± 6.5 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Cho et al. [52] RCT SMI group =15, SMIEx =15 15 45 SMI group = 36.60 ± 8.33, SMIEx = 36.00 ± 8.47 39.07 ± 10.99 N/M SMI group = 3, SMIEx = 4 3 10 SMI group =11, SMIEx = 10 10 31 N/M N/M N/M
Ghanbari et al. [53] RCT 15 15 30 37.66 ± 8.6 36.26 ± 7.46 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Ebneshahidi et al. [54] single blind, placebo RCT 25 25 50 33 (25-52) 38.6 (26-54) N/M 5 5 10 20 20 40 N/M N/M N/M
Abaschian and Mansoursohani 55] Single-blind, parallel-group RCT 12 12 24 37.4 + 9.24 32.55 + 7.65 N/M N/M N/M N/M N/M N/M N/M 25.27 + 4.36 25.12 + 4.55 N/M
Berggreen et al. [56] RCT 20 19 39 38.8 (13.7) 42.3 (10.2) N/M ALL females N/M N/M 20 19 39 N/M N/M N/M
Espí-López et al. [57] Double-blind RCT 62 divided to three sub groups 22 84 Treatment SI = 42.75 (18-65) , OAA =34 (18-50), SI and OAA = 40.70 (24-62) 41.95 (18-62) 39.76 (1 -65) Treatment SI = 5 , OAA =2, SI and OAA = 4 4 15 Treatment SI = 17 , OAA =20, SI and OAA = 18 18 68 N/M N/M N/M

Table 2. Baseline tension headache features of the participants.

Author, year, country Type of headache The pain intensity Duration of tension-type headache Frequency of tension-type headache Mean No. Of analgesics
Chronic TTH # Episodic TTH # Group 1 (Treatment) Group 2 (Control) Total Group 1 (Treatment) Group 2 (Control) Total Group 1 (Treatment) Group 2 (Control) Total Group 1 (Treatment) Group 2 (Control) Total
Damapong et al. [8] 55 N/M 6.3 + −1.2 6.06 + −0.94 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Gildir et al. [9] 160 N/M 4.5 ± 1.0 cm 4.6 ± 1.2 cm N/M 3.9 ± 0.7 hours/day 3.9 ± 0.7 hours/day N/M 18.5 ± 2.7 days/month 18.0 ± 2.4 days/month N\M N/M N/M N/M
Endres et al. [10] 93 (Group 1), 94 (Group 2) 116 (Group 1), 106 (Group 2) 68.3 ± 12.1 67.5 ± 12.5 N/M 11.2 ± 10.3 years 11.7 ± 10.7 years N/M 14 (12–18) days/4 weeks 14 (12–19) days/4 weeks N/M N/M N/M N/M
Mohamadi et al. [11] All participants N/M 7.46 ± 1.80 6.53 ± 1.89 N/M N/M N/M N/M 18.30 ± 6.29 days/month 16.69 ± 6.14 days/month N/M N/M N/M N/M
Soderberg et al. [12] 80 N\M N/M N/M N/M N/M N/M N/M 18.6 ± 6.7 days/month 20.5 ± 6.2 days/month and Group3: 18.2 ± 5.7 days/month N/M N/M N/M N/M
Kwon and Yoon [13] 33 N/M 35.36 ± 0.92 35.18 ± 1.25 and Group3:  35.36 ± 1.74 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Aslam et al. [14] 31 N\M 6.62 ± 1.58 6.73 ± 1.53 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Espí-López et al. [15] 17 21 6.5 N/M 6.5 N/M N/M N/M N/M N/M N/M N/M N/M N/M
Kamali et al. [16] N/M N/M Median 8.00 Median 9.50 N/M N/M N/M N/M Median 5 days/week Median 7 days/week N/M N/M N/M N/M
Saad (Nambi) et al. [17] 30 N/M Mean 6.26 (SD 0.86) Mean 6.45 (SD 0.96) N/M N/M N/M N/M Mean 4.73 days/week (SD 1.03) Mean 4.60 days/week (SD 0.91) N/M N/M N/M N/M
Espí-López et al. [18] 40.8% of 76 59.2% of 76 N/M N/M N/M N/M N/M N/M N/M 2.63 (pre-treatment frequency score for the control group) N/M N/M N/M N/M
Ferragut-Garcías et al. [19] 41.7% in Group A, 34.8% in Group B, 44.0% in Group C, 48.0% in Group D 58.3% in Group A, 65.2% in Group B, 56.0% in Group C, 52.0% in Group D Group A: 5.6 ± 1.1Group B: 4.4 ± 1.1 Group C: 5.7 ± 0.8Group D: 5.1 ± 1.0 N/M N/M N/M N/M Group A: 7.2 ± 2.7 days/15 daysGroup B: 8.6 ± 2.3 days/15 days Group C: 7.9 ± 2.7 days/15 daysGroup D: 8.0 ± 2.6 days/15 days N/M N/M N/M N/M
Ajimsha [20] 9 (16.1%) 47 (83.9%) N/M N/M N/M Group A: 7.1 ± 7.2 years Group B: 7.3 ± 8.1 yearsGroup C: 7.7 ± 7.7 years N/M Group A: 12.0 ± 2.8 days/4 weeks Group B: 12.4 ± 2.8 days/4 weeksGroup C: 12.0 ± 2.5 days/4 weeks N/M N/M N/M N/M
Castien et al. [21] 83 0 7.5 (1.7) P value not reported 7.7(1.6) P value not reported N/M 12.8(8.9) P value not reported 13.0(9.1) P value not reported N/M 23.7(6.8) P value not reported 24.0(7.0) P value not reported N/M N/M N/M 2
Hosseinifar et al. [22] 30 0 4.06 ± 0.69 P value =1.000 4.06 ±1.27 P value =1.000 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Gopichandran et al. [23] 169 0 6.7 ± 1.05 6.52 ± 1.2 N/M <1 year = 2 (2.4) > 1-2 year = 38 (45.2) >2-3 years = 30 (35.7) >3 years = 14 (16.6) <1 year = 5 (6) > 1-2 year = 32 (37.6) >2-3 years = 30 (35.2) >3 years = 18 (21.4) N/M 19.44 ± 1.56 p = -0.03 (0.97) 19.43 ± 1.18 p = -0.03 (0.97) N/M Analgesics= 30 (35.3)Analgesics with amitriptyline and propranolol =  55 (64.7) Analgesics 30 (35.7). Analgesics with amitriptyline and propranolol = 54 (64.3) N/M
Shafiq et al. [24] N/M N/M mean pain intensity: 2.53 ± 0.51 Mean pain intensity 2.53 ± 051 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Pérez-Llanes et al. [25] 25 0 4.6 (SD = 2.87) 6.9 (SD = 1.33) N/M N/M N/M N/M N/M N/M N/M N/M N/M paracetamol, NSAIDs, antidepressants, anxiolytics.
Cabanillas-Barea et al. [26] 86 0 Actual pain: 1.75 ± 1.74, usual pain: 3.42 ± 1.81, worse pain: 6.227 ± 1.64 Actual pain: 2.04 ± 1.76, usual pain 2.99 ± 1.46, worse pain: 6.14 ± 1.71 N/M N/M N/M N/M 13.28 ± 11.97 days/2 weeks 13.26 ± 12.39 days/2 weeks N/M NSAIDs 18, Acetaminophen and NSAIDs 8, Acetaminophen 16 NSAIDs 16, Acetaminophen and NSAIDs 7, Acetaminophen 16 N/M
Monti-Ballano et al. [27] CTTH and ETTH N/M N/M N/M N/M N/M N/M 13.69 ± 9.00 days/months 13.19 ± 11.55 days/months 13.44 ± 10.19 days/ months 18.94 ± 28.21 doses/months 39.81 ± 69.98 doses/months 29.38 ± 53.73 doses/months
Álvarez-Melcón et al. [58] 52 100 Mean intensity 5.82 (1.26) Mean intensity 5.57 (1.32) Total mean intensity 5.695 Mean duration 6.35 hours/day Mean duration 5.94 hours/day Total mean duration 6.15 hours/day Mean frequency 12.96 days in 4 weeks Mean frequency 12.71 days in 4 weeks Total 12.84 days Pre-treatment = 7.43 days in 4 weeks, post-treatment 5.13 days in 4 weeks, follow-up 4.19 days in 4 weeks Pre-treatment 7.46 days in 4 weeks, post-treatment 6.13 days in 4 weeks, follow-up 5.31 days in 4 weeks N/M
Park [28] Only chronic N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Chatchawan et al. [29] 42 0 5.54 ± 2.16 4.66 ± 2.40 5.10 ± 2.23 8.28 ± 13.81 hours 4.65 ± 4.67 hours N/M 16.26 ± 2.02 times/month 16.35 ± 6.68 times/month N/M 25 25 50
Choi et al. [38] 41 0 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Martín-Vera et al. [31] 40 0 6.9 ± 1.3 7.1 ± 1.6 N/M 18.3 ± 7.5 hours/month 14.0 ± 8.3 hours/month N/M 10.1 ± 9.5 days/month 10.5 ± 7.2 days/month N/M N/M N/M N/M
Gómez-Conesa et al. [32] 0.571 0.429 N/M N/M 6.49 (SD; 1.69) N/M N/M N/M N/M N/M N/M N/M N/M N/M
van Ettekoven et al. [33] ETTH and CTTH 5.72 5.86 N/M 8.1 hours per day 8.0 hours per day N/M 5.49 4.86 ns 1.13 days 0.98 days ns
Kanji et al. [34] All participants N/A 4.3 3.5 ns 8.3 hours per day 6.6 hours per day N/M 23.6 23.6 N/M N/M N/M N/M
Madsen et al. [35] N/M N/M 4.5 3.6 NS 252 hours per month (mean) 198 hours per month (mean) N/M 19 days 17 days N/M 3.5 days 4.7 days N/M
Xue et al. [36] 11 in group A , 11 in group B 9 in each group 45.2 (2.4) 49.3 (2.4) N/M 47.7 (7.4) 40.8 (4.8) N/M 13.8 (1.7) 12.5 (1.6) N/M N/M N/M N/M
Moraska et al. [37] 64.7 % in massage group, 52.6% in placebo group 35.3% in massage group, 47.4% in the placebo group 31.4 ± 2.69 33.3 ± 2.52 N/M 3.15 ± 0.43 3.20 ± 0.55 N/M 3.72 ± 0.23 3.81 ± 0.21 N/M Dose/week = 2.97± 0.82 Dose/week = 1.75± 0.76 N/M
Rinne et al. [38] N/M N/M 4.7 (95% confidence intervals, CI 4.4 to 5.0) 4.8 (4.5 to 5.1) N/M 30.8 (95% CI 24.7 to 36.9) hours/week in the exercise group 30.5 (23.9 to 37.1) in the control group N/M 4.5 (95% CI 3.9 to 5.1) in the exercise group and 4.4 (3.6 to 5.1) in the control group N/M N/M N/M N/M
Karst et al. [39] 25 in treatment, 22 in placebo 9 in treatment group , 12in placebo group 6.4 (2.0) 6.3 (1.9) N/M N/M N/M N/M 21.1 (10.2) 20.5 (10.3) N/M Analgisics/month 9.0 (11.1) Analgisics/month15.6 (32.4) N/M
Torelli et al.[40] 8 in treatment group , 16 in control group 16 in treatment group , 8 in control 1.6 (1-3) 1.7 (1-3) N/M 9.8 (7-16) 12.0 (5-22) N/M 14.5 (11-18) 18.1 (13-22) N/M 19.7 (5-33) 23.6 (6-32) N/M
Bove and Nilsson [41] N/M N/M Per day (95% CI) 37/100 (33-41/100) 37/100 (33-41/100) 38/100 (35-41/100) per day (95% CI) 2.8 (2.1-3.5) 3.4 (2.4-4.4) 3.1 (2.5-3.7) N/M N/M N/M Per day (95% CI)0.66 (0.49-0.83) 0.82 (0.50-1.14) 0.74 (0.56-0.92)
Hamed [42] N/M N/M group A = 70 ± 1, Group b = 71 ± 12 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Karakurum et al. [43] 20 (66.7%) , 8 (26.7%) episodic and 2 (6.7%) had episodic TTH in combination with migraine without aura. N/M N/M N/M N/M N/M N/M 29.6/month 25.2/month N/M N/M N/M N/M
Cabanillas-Barea et al. [44] N/M N/M 1.75 (1.74) 2.04 (1.77) N/M N/M N/M N/M 13.28 (11.90) 13.26 (12.29) 14 (35%) for Acetaminophen, 18 (45%) for NSAIDs 16 (41%) for Acetaminophen, 16 (41%) for NSAIDs N/M
Corum et al. [45] 3 in group A, 5 Group B, 4 Group C 9 in group A,10 Group B, 8 Group C Group A =5.6 ± 1.1, Group B= 5.8 ± 1.1 5.8 ± 1.2 N/M N/M N/M N/M Group A (Day/2 week) = 5.4 ± 2.3, Group B (Day/2 week)= 5.6 ± 2.5 Day/ 2 week =5.8 ± 2.7 N/M N/M N/M N/M
Sertel and Bakar [46] N/M N/M BAT = 6.15 ± 0.74, AE = 6.1 ± 1.02 5.90 ± 0.71 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Kwon et al. [47] N/M N/M 6.27 ± 1.38 5.33 ± 1.17 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Espí-López et al. [48] 24 in control group, 25 in treatment group 27 (control group, 26 in treatment group) N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Azhdari et al. [49] N/M N/M 7.37 (2.01) 6.70 (2.37) N/M 344.18 (333.39) 279.05 (165.66) N/M 4.91 (2.39) 5.25 (2.05) N/M N/M N/M N/M
Georgoudis et al. [50] N/M N/M 6.5 ± 2.5 7.8 ± 1.8 N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Georgoudis et al. [51] N/M N/M N/M N/M N/M N/M N/M N/M 8.1 ± 2.8 8.2 ± 3.6 N/M N/M N/M N/M
Cho et al. [52] N/M N/M N/M N/M N/M SMI group =3.63 ± 1.67 (years), SMIEx = 3.29 ± 2.22 (years) 3.28 ± 1.43 N/M N/M N/M N/M N/M N/M N/M
Ghanbari et al. [53] N/M N/M 5.80 ± 1.75 6.03 ± 0.99 N/M 6.42 ± 5.70 5.37 ± 3.47 N/M 12.40 ± 2.22 11.13 ± 1.99 N/M N/M N/M N/M
Ebneshahidi et al. [54] N/M N/M 10 (3.0) 10 (1.0) N/M 10 (4.0) 8 (4.5) N/M N/M N/M N/M N/M N/M N/M
Abaschian and Mansoursohani [55] N/M All cases (24) 6.08 + 1.32 4.83 + 1.37 N/M N/M N/M N/M 11.44 + 3.77 11.06 + 3.36 N/M N/M N/M N/M
Berggreen et al. [56] N/M N/M 28.0 (15.9) 26.6 (12.6) N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Espí-López et al. [57] N/M N/M Treatment SI = 4.79 (2.26), OAA = 5.12 (1.95), SI and OAA = 4.80 (1.68) 5.24 (1.80) N/M N/M N/M N/M Treatment SI = 3.25 (2.29), OAA =2.90 (1.86), SI and OAA = 55.67 (7.74) 3.24 (1.57) N/M N/M N/M N/M

Figure 2. Risk of bias summary using ROB-2 quality assessment tool for the included randomized clinical trials.

Discussion

This systematic review synthesized evidence from 51 randomized controlled trials to evaluate the effectiveness of physical therapy for TTH. The comprehensive analysis of over 3,400 participants confirms that physical therapy is a robust, non-pharmacological treatment option.

The results align with the multifactorial pathophysiology of TTH. Our analysis supports the findings of Repiso-Guardeño et al. [59], whose systematic review highlighted the efficacy of manual therapy in reducing central sensitization. Similarly, Cumplido -Trasmonte et al. [60] emphasized that manual therapy techniques are particularly effective for adults with chronic TTH when applied to the cranio-cervical region.

Regarding multimodal care, our review suggests that combining passive therapies with active exercise yields superior outcomes. This is consistent with the recent meta-analysis by Onan et al. [61], which concluded that physiotherapy approaches are most effective when tailored to address both muscular tension and functional disability. Furthermore, Qin et al. [62] noted that complementary strategies, including acupuncture, significantly reduce headache frequency compared to routine care.

Safety remains a key advantage of physical therapy. Krøll et al. [63] reported that adverse events in non-pharmacological interventions are rare and mild. Our review corroborates this, as the included RCTs (Appendix A) reported mostly transient muscle soreness, reinforcing physical therapy as a safe alternative for patients at risk of medication-overuse headaches.

Despite the heterogeneity in treatment protocols—ranging from single sessions to 12-week programs—the consistent positive outcomes across diverse populations strengthen the external validity of these findings. However, as noted by Jung et al. [64], the quality of evidence is often limited by short follow-up periods, necessitating future research with longer observation timelines.

Table 3. Characteristics of the physiotherapies conducted in TTH patients.

Author, year, country Type of physiotherapy used Home based program Conducted by qualified physiotherapist Duration of physiotherapy Number of sessions Follow up period Withdraw ( N ) Withdrawal reasons
Group 1 (Treatment) Group 2 (Control) Group 1 (Treatment) Group 2 (Control) Total
Damapong et al. [8] Court type traditional Thai massage  Amitriptyline N/M Yes 45 minutes per session, twice a week for 4 weeks  8 2 weeks  None  None  None  N/A
Gildir et al. [9] Trigger point dry needling (DN) Sham dry needling (SDN) No Yes 3 sessions/week for 2 weeks 6 sessions (for each group) 1 month 0 1 1 1 patient in the control group used tricyclic antidepressants
Endres et al. [10] Verum acupuncture Sham acupuncture No Yes 10 sessions over 6 weeks (with an additional 5 sessions for partial response) 10 (or up to 15 for partial response) 6 months 5 6 11 N/M
Mohamadi et al. [11] Positional release technique (PRT) Ibuprofen 200mg No Yes 10 sessions over 5 weeks (2 sessions per week) 10 sessions 5 weeks 2 3 5 Ineligibility (detected by MRI) or discomfort with the procedures
Soderberg et al. [12] Acupuncture Physical training (strength and endurance) and Group3: Relaxation training No Yes 12 weeks 24 sessions 6 months 1 2 and Group3: 1 4 N/M
Kwon and Yoon [13] Temporomandibular joint and cervical vertebra treatment Temporomandibular joint treatment and Group3: Cervical vertebra treatment NO Yes 4 weeks, 3 times per week, 50 minutes per session 12 sessions N/M N/M N/M N/M N/M
Aslam et al. [14] Trigger point release therapy (20 minutes) Heat therapy, TENS, and stretching exercises No Yes 3 sessions over 1 week 3 N/M N/M N/M N/M N/M
Espí-López et al. [15] Suboccipital inhibitory pressure (SI), suboccipital manipulation (SM), combination None N/M Yes 4 weeks  4 sessions  1 month  None  None  None None 
Kamali et al. [16] Dry needling versus friction massage at myofascial trigger points Manual circular pressure instead of needles  N/M N/M 1 week  3 sessions  48 hours after the last session N\M N\M 4 1 withdrew due to needle phobia, 3 did not attend the follow-up
Saad (Nambi) et al. [17] Instrument-assisted soft tissue mobilization (IASTM) Conventional physical therapsy  N\M Yes 4 weeks  12 sessions  Post-treatment evaluation after 4 weeks 1 1 2 N/M
Espí-López et al. [18] Suboccipital soft tissue inhibition (SI), Occiput-Atlas-Axis (OAA) manipulation, combination None No Qualified physiotherapists with >10 years of experience 4 weeks  4 sessions 4 weeks  N/M N/M N/M N/M
Ferragut-Garcías et al. [19] Group A: Placebo superficial massageGroup B: Soft tissue techniques Group C: Neural mobilization techniquesGroup D: Combined soft tissue and neural mobilization techniques No Qualified physiotherapists 4 weeks 6 (15 minutes per session) 30 days N/M N/M N/M N/M
Ajimsha [20] Group A (DT-MFR): Direct technique myofascial release (3 minutes on each side for multiple head, neck, and face regions) Group B (IDT-MFR): Indirect technique myofascial release (10-minute stretches and pulls) Group C (Control): Slow soft stroking over the head No Certified myofascial release practitioners 12 weeks (2 sessions per week) 24 4 weeks post-intervention (Weeks 17-20) Group A: 2 Group B: 2Group C: 1 5 Not provided
Castien et al. [21] Combination of mobilisations of the cervical and thoracic spine, exercises and postural correction GP  yes yes 30 minutes with a maximum of nine treatments  N/M N/M none none none N/M
Hosseinifar et al. [22] MFR technique and exercise therapy No intervention No Yes Each session last 45 minutes 4 times a week for 3 weeks At least 3 months None None None N/M
Gopichandran et al. [23] Perform PMR and deep breathing exercises Standard routine care  Yes Yes 20 minutes daily in the evening with an instruction booklet Were asked to perform them for 12 weeks 2 weeks- 6 weeks- 12 weeks None None None N/M
Shafiq et al. [24] Soft tissue mobilization and trigger point release Stretching  N/M yes  3 weeks  9 sessions  N/M N/M N/M 22 N/M
Pérez-Llanes et al. [25] Suboccipital muscle inhibition, interferential current therapy  Received standard treatment  N/M Yes  4 weeks 8 sessions  4 weeks  0 3 3 Due to lack of adherence to the study 
Cabanillas-Barea et al. [26] Diacutaneous fibrolysis None N/M Yes  1 week  3 sessions  1 month N/M N/M 7 4 did not complete the intervention protocol, 3 did not attend the evaluation sessions 
Monti-Ballano et al. [27] Dry needling  None N/M N/M N/M 3 sessions  N/M N/M N/M N/M N/M
Álvarez-Melcón et al. [58] Combination of relaxation techniques and physical therapy, AutogenicTraining (AT), Cervical spine kinesiotherapy, posture correction.  Relaxation techniques only (Autogenic training) Yes Yes  3 weeks  28 sessions  3 months  4 4 8 N/M
Park et al. [28] Manual therapy (relaxation approaches+self exercise at peri-neck musscles  Conventional rehabilitation approaches  N/M Yes  4 weeks  12 sessions  N/M N/M N/M N/M N/M
Chatchawan et al. [29] Combined massage for 25 minutes and stretching for 5 minutes according to the pattern of royal Thai massage Sham US application of a detuned device with circular kneading on the upper neck or upper back in the supine and side lying poisitions  N/M Yes  3 weeks  9 sessions 12 weeks  6 5 11 Mild fever, mild soreness, and discomfort.
Choi et al. [30] Temporomandibular joint therapy, Cervical manual therapy  Conservative percutaneous stimulation therapy, ultrasound therapy, and warm compress  N/M Yes  3 weeks  3 sessions  N/M N/M N/M 4 N/M
Martín-Vera et al. [31] The participants performed specific exercises for craniocervical, shoulder girdle, shoulder muscles. Daily activities without monitoring  Yes  Yes  12 weeks  2 day in first 6 weeks, 3 days the last 6 weeks  N/M N/M N/M N/M N/M
Antonia (Gomez) et al. [32] Manipulative treatment, manual therapy, andcombined treatment Did not receive treatment but stayedin the supine position with neutral ranges for 10 minutes N/M Yes Four treatment sessions (1 session per week) wereadministered, with an interval of 7 days, Each session lasted for approx-imately 20 minutes. 4 8 weeks 2 participants 2 participants 4 Control group: 1 due to transient illness, 1 for no pain relief. treatment group: 1 due to mild cervical pain, 1 for personal reasons.
van Ettekoven et al. [33] Standard physiotherapy and craniocervical training Standard physiotherapy only Yes, participants practiced craniocervical training at home twice daily Yes 6 weeks NS Immediately after treatment and at 6 months 1 2 3 NS
Kanji et al. [34] Sauna bathing 3 times per week for 20 minutes and education and self-directed soft tissue massage   Education and self-directed soft tissue massage Yes (self-directed soft tissue massage) N/M 8 weeks (sauna intervention period) 3 times a week (Group 1) 12 weeks 2 4 6 N/M
Madsen et al. [35] Strength training (progressive with elastic resistance bands) Ergonomics and posture correction Yes (self-directed exercises in both groups) Yes 10 weeks 3 times per week for the strength training group 19–22 weeks 7 9 16 N/M
Xue et al. [36] Group A had real electroacupunc-ture (REA) in phase I, then SEA in phase II. Group B reGroup B had SEA in phase I, then REA in phase II. N/M N/M 6 weeks N/M 3 months N/M N/M N/M N/M
Moraska et al. [37] Myofascial Trigger Point-focused Head and Neck Massage Placebo (detuned ultrasound) N/M N/M Over 6 weeks, N/M 4weeks 4 2 6 N/M
Rinne et al. [38] Exercise (three included low-load exercises for the neck–shoulder region, and the remaining  three specific strengthening exercises for the neck and upper body Placebo-dosed treatment with 20 minutes of transcutaneous electrical nerve stimulation N/M N/M 6 months N/M 6-month period. 9 9 18 Personal reasons (9), un known reason (5), low back pain (1), maliase 1)
Karst et al. [39] Verum needle Seirin B-type needles no. 8 (0.3 × 0.3 mm) and no. 3 (0.2 × 0.15 mm) were used for verum acupuncture. Placebo needle The tip of the needle is blunt in order to cause a pricking sensation without actually puncturing the skin N/M N/M 6 weeks Two treatments per week for a total of 10 treatments. 6 month period N/M N/M N/M N/M
Torelli et al. [40] Standardized physiotherapy Observation period of similar length with clinic visits to the neurologist N/M N/M 8 weeks Twice a week for 4 weeks 12 weeks 6 6 11 N/M
Bove et al. [41] Joint manipulation of the cervical spine  Deep friction massage.  N/M N/M 4 weeks N/M N/M 2 2 4 N/M
Hamed et al. [42] Both group (A) and group (B) received standardized physiotherapy treatment program  Only analgesic medications  yes An educational session  8 weeks 3/week N/M N/M N/M N/M N/M
Karakurum et al. [43] Intramuscular stimulation  N/M N/M N/M N/M N/M N/M N/M N/M N/M
Cabanillas-Barea et al. [44] DF group received three interventions on alternate days.  Standard care intervention based on pharmacological therapy  N/M N/M 3 treatment session 3 1 month 1 2 3 N/M
Corum et al. [45] HVLA manipulation plus exercise (intervention) (group A)and; myofascial release group, which received suboccipital inhibition plus exercise Receive exercise only N/M N/M N/M N/M 3 month 1 3 4 Attendance failure = 3, received prophylactic treatment = 1
Sertel et al. [46] Treatment group (20 individuals), BAT program was applied, to the second group (20 individuals), the aerobic exercise program N/M N/M N/M N/M N/M N/M 2 0 2 1 had transport difficulty, 1 had family problems
Kwon et al. [47] Hamstring relaxation program (HR) Interferometric current treatment and infrared heat treatment simultaneously N/M N/M 8 weeks 3 session/week N/M N/M N/M N/M N/M
Espí-López et al. [48] N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M
Azhdari et al. [49] Myo-fascial release of SCM,  Drugs (nortriptyline 50 qsh and valporae Na 200 mg BID). N/M N/M 1 week 3/week 1 week 0 0 0 N/M
Georgoudis et al. [50] Acupuncture followed by stretching protocol followed by physiotherapy by microwave diathermy and myofascial release techniques. Biomedical acupuncture followed by stretching protocol N/M N/M N/M N/M N/M N/M N/M N/M N/M
Georgoudis et al. [51] Acupuncture followed by stretching protocol followed by physiotherapy by microwave diathermy and myofascial release techniques. Biomedical acupuncture followed by stretching protocol N/M N/M N/M N/M N/M N/M N/M N/M N/M
Cho et al. [52] Sub- occipital muscle inhibition for one group and another group SMI with FHP correction exercises (SMIEx) None N/M N/M 4weeks 2/week N/M 2 2 4 N/M
Ghanbari et al. [53] Positional Release Therapy Medication therapy N/M N/M 2 weeks 5 session in 2 weeks 2 weeks N/M N/M N/M N/M
Ebneshahidi et al. [54] low energy laser acupuncture to LU7, LI4,GB14, and GB20 bilaterally. A similar way except that the output power of the equipment was set to zero. N/M N/M 1 month 10session, 2 per week 3 month N/M N/M N/M N/M
Abaschian et al. [55] dry needling with passive stretching treatment Received only passive stretching. N/M N/M 4 weeks N/M N/M N/M N/M N/M N/M
Berggreen et al. [56] (one session of trigger point massage per week for 10 weeks) None N/M N/M 4 weeks N/M 4 weeks 1 3 4 One participant in the treatment group left the study after seven treatments because of unbearable pain. One participant in the control group was excluded because she started treatment elsewhere. Two participants from the control group did not fill out the diary and questionnaires at follow-up.
Espí-López et al. [57] SI treatment  None N/M N/M 4 weeks N/M 8 weeks 2 2 2 in treatment group by OAA due to adverse effect, 2 in control group due to not feeling of improvement N/M

Table 4. Summary of clinical outcomes and adverse events of the included studies.

Study (References) Pain intensity outcomes (group 1 vs. group 2) Frequency and duration outcomes Adverse events/complications
Damapong et al. [8] Significant reduction: 2.6 ± 0.7 vs. 2.9 ± 1.0 (p < 0.05) No significant difference in frequency. Mild ache in shoulders (group 1); drowsiness (group 2).
Gildir et al. [9] Significant reduction: 0.7 ± 0.8 vs. 4.6 ± 0.7 cm (p < 0.001). Frequency reduced: 3.8 ± 1.8 vs. 7.9 ± 2.0 days/month (p < 0.001). Pain and fear during procedure; One severe headache in sham group.
Endres et al. [10] No significant difference: 68.3 ± 12.1 vs. 67.5 ± 12.5. Frequency: 6.0 vs. 8.4 days/4 weeks (p = 0.002). One severe headache; 10 serious events reported (mostly unrelated).
Mohamadi et al. [11] Significant reduction: 4.38 ± 1.66 vs. 7.00 ± 1.47 (p = 0.002). Frequency reduced: 5.84 ± 3.76 days/month (p = 0.001). None reported.
Söderberg et al. [12] N/M Frequency reduced: 11.1 ± 8.4 vs. 14.0 ± 9.3 days/month (p < 0.001). None reported.
Kwon et al. [13] Significant reduction: 22.64 ± 1.80 vs. 26.45 ± 2.42 (p = 0.001). N/M None reported.
Aslam et al. [14] Significant reduction: 3.75 ± 1.39 vs. 5.93 ± 1.62 (p < 0.001). N/M None reported.
Espí-López et al. [15] Significant reduction (p = 0.02). N/M None reported.
Kamali et al. [16] Significant reduction: Mean 3.00 vs. 4.22 (p < 0.05). Mean frequency: 1.95 vs. 2.85. None reported.
Saad (Nambi) et al. [17] Significant reduction: Mean 4.34 vs. 2.29 (p < 0.05). Mean frequency: 2.83 vs. 1.73. None reported.
Espí-López et al. [18] Significant reduction (p < 0.05). Significantly reduced frequency (p < 0.05). N/M
Ferragut-Garcías et al. [19] Significant reduction in combined group (p < 0.001). Frequency reduced significantly in combined group (p<0.001). N/M
Ajimsha et al. [20] N/M Frequency reduced: 4.9 ± 1.7 vs. 10.4 ± 2.7 days/4 weeks (p < 0.001). No serious adverse events; some mild headaches reported.
Castien et al. [21] Significant difference: 1.8 points improvement. Frequency difference: 6.4 days (p < 0.001). No adverse events were reported.
Hosseinifar et al. [22] Significant reduction: 2.33 ± 1.11 vs. 4.06 ± 1.16 (p = 0.000). N/M No side effects.
Gopichandran et al. [23] Significant reduction at 12 weeks: 2.84 ± 1.49 (p < 0.001). Frequency reduced: 15.03 ± 3.39 (p < 0.001). No any side effect.
Shafiq et al. [24] N/M Frequency reduced from >5/week to 1/week. N/M
Pérez-Llanes et al. [25] No significant difference in pain intensity (p = 0.27). N/M No adverse events reported.
Cabanillas-Barea et al. [26] Change: –0.88 vs. 0.22. Significant between-group change (p < 0.001). Frequency Change: –7.45 vs. 2.31 (p < 0.001). N/M
Monti-Ballano et al. [27] Pain intensity: 10.50 ± 16.79 vs. 27.93 ± 52 (p = 0.160). Frequency reduced: 13.00 vs. 46.63 days/month (p = 0.009). N/M
Álvarez-Melcón et al. [58] Significant reduction: Mean 4.23 vs. 4.58 (p < 0.001). Duration reduced (p < 0.001). N/M
Park et al. [28] N/M Frequency reduced: 9.10 vs. 10.25 days/4 weeks (p < 0.001). N/M
Chatchawan et al. [29] Significant reduction: 2.32 vs. 2.93 (p < 0.001). Duration reduced: 6.88 vs. 10.38 hours. Mild fever, mild soreness, and discomfort.
Choi et al. [30] Significant reduction: 5.1 ± 2.1 vs. 7.1 ± 1.6 (p = 0.001). Frequency: 7.4 vs. 10.5 days/month (p = 0.109). N/M
Martín-Vera et al. [31] Significant reduction: 5.1 ± 2.1 vs. 7.1 ± 1.6 (p = 0.001). Frequency: 7.4 vs. 10.5 days/month. N/M
Antonia (Gomez) et al. [32] Significant reduction with combined treatment (p = 0.001). N/M N/M
van Ettekoven et al. [33] N/M Frequency reduced: 1.95 days/week (p < 0.0001). N/M
Kanji et al. [34] Significant reduction (44%, p < 0.0001). No significant change in frequency. Lack of quantification of sauna attendance; no adverse effects.
Madsen et al. [35] No significant difference (p = 0.231). Frequency reduced: 19 to 17 days (p = 0.041). N/M
Xue et al. [36] Significant reduction: 13.3h vs. 6.3h (duration/pain). Frequency reduced: 3.0 vs. 1.2 per month. N/M
Moraska et al. [37] No significant difference (p = 0.3). Frequency: 3.38 vs. 3.21 (p = 0.026). N/M
Rinne et al. [38] No between-group difference (p = 0.66). Duration decreased but no sig diff (p = 0.24). Feasible and safe to perform.
Karst et al. [39] N/M No significant differences in frequency. N/M
Torelli et al. [40] N/M Reduced days: 14.5 to 10.5 (p < 0.001). N/M
Bove et al. [41] No significant effect. Duration unchanged. N/M
Hamed et al. [42] Significant reduction (p = 0.0001). Decrease in headache frequency. N/M
Karakurum et al. [43] N/M Frequency: 29.6 vs. 25.2/month. N/M
Cabanillas-Barea et al. [44] Significant reduction: 0.86 vs. 1.82 (p < 0.003). Frequency reduced: 5.82 vs. 15.49 (p < 0.001). N/M
Corum et al. [45] Significant diff between manipulation and soft tissue (p = 0.014). Frequency improvement (p < 0.001). N/M
Sertel et al. [46] Significant reduction: 2.50 vs. 5.65 (p = 0.001). N/M N/M
Kwon et al. [47] Significant reduction: 2.73 vs. 3.13 (p = 0.057). N/M N/M
Espí-López et al. [48] N/M N/M N/M
Azhdari et al. [49] Significant reduction: 3.04 vs. 6.75 (p = 0.001). Frequency reduced: 4.91 vs. 5.25. N/M
Georgoudis et al. [50] Significant effect of time on VAS (p<.001). N/M N/M
Georgoudis et al. [51] N/M Frequency: 3.25 vs. 4.50 (p = 0.004). N/M
Cho et al. [52] N/M N/M N/M
Ghanbari et al. [53] No significant difference (p = 0.486). Frequency: 9.33 vs. 10.03 (p = 0.508). N/M
Ebneshahidi et al. [54] Significant reduction: –5 vs. −1 (p = 0.001). Duration reduced: –6 vs. –1 hours (p = 0.001). N/M
Abaschian et al. [55] Significant reduction: 5.52 vs. 5.12 (p = 0.001). Frequency: 10.33 vs. 11.77 (p = 0.018). N/M
Berggreen et al. [56] Significant reduction (p = 0.047). N/M N/M
Espí-López et al. [57] Significant reduction (p = 0.03). N/M N/M

Conclusion

Based on high-quality evidence from 51 RCTs, physical therapy is an effective and safe intervention for TTH. It significantly reduces headache burden with minimal risk of adverse events. To optimize clinical practice, a multimodal approach combining manual therapy and active exercise is recommended. Future studies should focus on long-term follow-up and standardized treatment protocols.

Acknowledgments

None.

List of Abbreviations

GBD global burden of disease

NSAIDs non-steroidal anti-inflammatory drugs

PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PROSPERO International Prospective Register of Systematic Reviews

RCTs randomized controlled trials

TTH tension-type headache

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this paper.

Funding

None.

Ethical approval

Not applicable (Systematic review of existing literature).

Author details

Adnan Ahmed Badahdah1, Majed Hassan Alahmadi2, Gharam Abdulaziz Alahmadi3, Mohamad Bassel Dahha3, Amal Abdullah Alzahrani4, Ahad A. Alkenani5, Yazeed Abdulrahman Alqahtani6, Khalid M. Alrashidi7, Nourah Ali Alqhtani8, Amjad Adel Alosaimi9, Bashayer N. Alkorbi10

  1. Department of Medicine, University of Jeddah, Jeddah, Saudi Arabia
  2. Radiology Department, Royal Commission Hospital, Yanbu, Saudi Arabia
  3. College of Medicine, Ibn Sina National College, Jeddah, Saudi Arabia
  4. College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
  5. Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
  6. College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
  7. College of Medicine, University of Hail, Hail, Saudi Arabia
  8. College of Applied Medical Sciences, Tabuk University, Tabuk, Saudi Arabia
  9. College of Medicine, Taif University, Taif, Saudi Arabia
  10. College of Medicine, Najran University, Najran, Saudi Arabia

Supplementary content (If any) is available online.

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Keywords: Headache, tension-type headache, physical therapy, physiotherapy, manual therapy.

Open access Creative Commons License
Publication History

Received: April 03, 2026

Revised: May 31, 2026

Accepted: June 03, 2026

Published: August 15, 2026

Authors

Adnan Ahmed Badahdah

Department of Medicine, University of Jeddah, Jeddah, Saudi Arabia.

Majed Hassan Alahmadi

Radiology Department, Royal Commission Hospital, Yanbu, Saudi Arabia.

Gharam Abdulaziz Alahmadi

College of Medicine, Ibn Sina National College, Jeddah, Saudi Arabia.

Mohamad Bassel Dahha

College of Medicine, Ibn Sina National College, Jeddah, Saudi Arabia.

Amal Abdullah Alzahrani

College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.

Ahad A. Alkenani

Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.

Yazeed Abdulrahman Alqahtani

College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

Khalid M. Alrashidi

College of Medicine, University of Hail, Hail, Saudi Arabia.

Nourah Ali Alqhtani

College of Applied Medical Sciences, Tabuk University, Tabuk, Saudi Arabia.

Amjad Adel Alosaimi

College of Medicine, Taif University, Taif, Saudi Arabia.

Bashayer N. Alkorbi

College of Medicine, Najran University, Najran, Saudi Arabia.