BACKGROUND Malnutrition is a major problem in head and neck cancer (HNC) with up to half of patients requiring gastrostomy tube (G-tube) placement. Predicting this need remains complex given mixed evidence surrounding its usage. METHODS A comprehensive search was performed to identify studies examining risk factors associated with G-tube placement following radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) in HNC patients. RESULTS Sixteen retrospective studies were included (n = 11 015). The overall prevalence of G-tube placement was 44% with 76% of patients receiving reactive G-tube placement. Pretreatment dysphagia, pretreatment BMI < 18.5, and tumors in the hypopharynx were significant predictive factors for prophylactic G-tube placement. Type of chemotherapy regimen, tumors in the nasopharynx, and cytokine changes were significant predictive factors for reactive G-tube placement. CONCLUSIONS Several factors were identified that contribute to increased risk of G-tube placement and may guide current decision-making algorithms.