A systematic review of RCTs was conducted to assess the effectiveness of physiotherapy and (spinal) manipulation in patients with tension-type headache (TTH). Literature was searched using a computerised search of Medline, Embase and the Cochrane library. Only RCTs including physiotherapy and/or (spinal) manipulation used in the treatment of TTH in adults were selected. Two reviewers independently assessed the methodological quality of the RCTs using the Delphi list. A study was considered of high quality if it satisfied at least six points on the methodological quality list. Twelve publications met the inclusion criteria, including three dual or overlapping publications, resulting in eight studies being included. These studies showed a large variety of interventions, such as chiropractic spinal manipulation, connective tissue manipulation or physiotherapy. Only two studies were considered to be of high quality, but showed inconsistent results. Because of clinical heterogeneity and poor methodological quality in many studies the authors conclude that there is insufficient evidence to either support or refute the effectiveness of physiotherapy and (spinal) manipulation in patients with TTH.