Systematic Review Will Test Whether Exercise Reduces Tension-Type Headache Burden
Exercise has become a recurring part of tension-type headache care, but the evidence base still reads like a collection of partly comparable, partly incompatible trials. This BMJ Open protocol sets out to organize that literature with a systematic review and meta-analysis focused on adults with tension-type headache, the most common primary headache disorder worldwide. The planned work is designed to move beyond the simple question of whether exercise helps and address a more frustrating one in clinical research: which exercise programs are described well enough, delivered consistently enough, and dosed clearly enough to allow meaningful interpretation.
The protocol centers on randomized controlled trials and will search PubMed, Embase, Scopus, Web of Science, PEDro, and CENTRAL from inception through June 2026. Two reviewers will independently screen studies, extract data, and assess bias using the Cochrane Risk of Bias 2 tool. Primary outcomes are headache frequency and pain intensity. Secondary outcomes include disability, quality of life, and medication use.
The design is practical in a way headache research often is not. Exercise is already being used in clinics and by patients trying to manage persistent head pain without relying entirely on medication, yet trial methods vary widely enough that pooled estimates can blur more than they clarify.
Reporting Quality May Explain Why Earlier Exercise Trials Have Been Hard To Compare
One of the most useful features of this protocol is its explicit attention to reporting completeness. The review will use the Consensus on Exercise Reporting Template, or CERT, to assess how completely each intervention is described. In exercise trials, omission of basic details can be a major barrier to interpretation: the exact type of exercise, progression, intensity, supervision, adherence, and tailoring often determine whether an intervention can be reproduced at all.
Poor reporting does more than frustrate readers. It weakens translational value. A headache therapist, neurologist, or primary care clinician cannot reasonably apply results from a trial if the exercise prescription is vague or underdescribed. CERT scoring in this review is meant to quantify that problem rather than leave it as an impressionistic critique.
The protocol also plans exploratory meta-regression analyses to examine whether reporting completeness, exercise dose, and intervention type are associated with treatment effects. In theory, this could help separate an actually ineffective intervention from one that looked ineffective because the underlying program was inconsistent, underdosed, or impossible to reproduce across sites. Exercise may reduce headache burden through several plausible mechanisms, including neuromuscular adaptation, improved pain modulation, and greater self-efficacy, but those mechanisms can only be evaluated credibly when the intervention itself is visible in enough detail.
Headache Frequency, Pain Intensity, and Medication Use Will Anchor the Analysis
The review’s primary outcomes are clinically grounded. Headache frequency captures how often patients are disrupted by pain, while pain intensity reflects the immediate symptom burden. Secondary outcomes extend the analysis toward function and day-to-day impact, including disability and quality of life, along with medication use. For a disorder as common as tension-type headache, these endpoints matter because treatment success is rarely defined by one narrow metric alone.
Random-effects meta-analysis will be used, an appropriate choice when heterogeneity is expected across exercise types, settings, comparators, and participant populations. The team will assess statistical heterogeneity with Cochran’s Q, I², and, where applicable, variance components from multilevel models. Those measures will matter because headache exercise studies often differ in duration, supervision level, treatment frequency, and whether the intervention is framed as strengthening, mobility work, aerobic training, or a broader physical activity prescription.
A single pooled estimate may therefore be informative, but only if it is interpreted alongside the spread of the underlying evidence. Large variation across trials would not be surprising here. It would reflect the reality that exercise is not one therapy but a family of interventions with different physiological and behavioral targets.
Why This Protocol Could Improve Clinical Interpretation Instead of Just Repeating the Literature
The protocol’s strongest contribution may be methodological rather than therapeutic. By pairing meta-analysis with reporting assessment, the review tries to answer not only whether exercise works, but whether the literature is sufficiently detailed to support trustworthy conclusions. That distinction matters in headache care, where treatment effects are often modest and highly sensitive to how an intervention is delivered.
If the CERT assessment shows persistent gaps, those gaps may help explain why earlier systematic reviews have reached inconsistent conclusions. Trials with incomplete reporting can inflate uncertainty even when their results trend in the same direction, and they can also obscure dose-response relationships that matter in rehabilitation medicine. A poorly described program that appears to reduce headache burden is difficult to translate into practice; a well-described program that fails to help is far more informative.
The planned use of the GRADE approach adds another layer of clinical discipline. Evidence certainty will be judged explicitly, which should help readers distinguish between promising signals and robust guidance. For clinicians, that distinction is central. A systematic review can be statistically sophisticated and still leave uncertainty intact if the underlying studies are too heterogeneous or poorly reported to support confident recommendations.
What the Completed Review Will Still Need To Resolve
The protocol is limited by the evidence base it will inherit. Its conclusions will depend on the size, quality, and consistency of the available randomized trials, and the authors have already signaled the possibility of substantial heterogeneity. That is a serious issue in a field where exercise programs vary in content and are often described with too little precision to support apples-to-apples comparisons.
The review also cannot create better trials than those already published. If the literature lacks clear exercise prescriptions, adherence data, or standardized comparator groups, meta-regression may identify patterns but not fully settle causality. Even so, the planned work should clarify whether the apparent benefit of exercise in tension-type headache is stable across studies or concentrated in better-reported interventions with clearer dose structures.
Ethical approval is not required because the project uses published data only. Findings will be submitted to a peer-reviewed journal and presented at scientific conferences. With registration in PROSPERO under CRD420261377102, the analysis is positioned to offer a more disciplined read on a therapy that has entered practice faster than the evidence has settled.