To the knowledge of the authors, this is the first systematic review dealing with the efficacy of manual therapy randomized clinical trials (RCT) for primary chronic headaches. A comprehensive English literature search on CINHAL, Cochrane, Medline, Ovid and PubMed identified 6 RCTs all investigating chronic tension-type headache (CTTH). One study applied massage therapy and five studies applied physiotherapy. Four studies were considered to be of good methodological quality by the PEDro scale. All studies were pragmatic or used no treatment as a control group, and only two studies avoided co-intervention, which could result in possible bias and makes interpretation of the results more challenging. The RCTs indicate that massage and physiotherapy are effective treatment options in the management of CTTH. One of the RCTs showed that physiotherapy decreased headache frequency and intensity statistical significant better than usual care by the general practitioner. The efficacy of physiotherapy at post-treatment and at 6 months follow-up is equal to the efficacy of tricyclic antidepressants. Effect size of physiotherapy was up to 0.62. Future manual therapy RCTs are requested dealing with the efficacy in chronic migraine with and without medication overuse. Future RCTs on headache should adhere to the International Headache Society’s guidelines for clinical trials, i.e., frequency as primary end-point, while duration and intensity should be secondary end-point, avoid co-intervention, include adequate sample size and follow-up period for no fewer than 6 months.
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