Purpose: To evaluate the effect of music therapy on anxiety, physiological indicators and successful colon intubation rate in patients undergoing colonoscopy. Methods: Randomized controlled trials (RCTs) on music therapy during colonoscopy published up to December 2025 were retrieved from 8 databases. Study quality was assessed using the Cochrane risk-of-bias tool (ROB 2.0), and meta-analysis was performed with R software. Results: 25 RCTs involving 4,525 patients were included. Music therapy significantly reduced anxiety (SMD = -0.61; 95% CI [-0.84, -0.38]; p < 0.0001), systolic blood pressure (MD = -8.63; p = 0.015), diastolic blood pressure (MD = -0.92; p = 0.034), mean arterial pressure (MD = -7.77; p = 0.005) and heart rate (MD = -11.65; p < 0.0001), and improved intubation success rate (RR = 1.04; p = 0.002). No significant effect on respiratory rate was observed. Results were robust, but study quality was generally low. Conclusions: Music therapy is safe and effective for alleviating anxiety and improving physiological indicators in colonoscopy patients, warranting clinical promotion. More high-quality RCTs are needed.