Occipital nerve stimulation for intractable chronic cluster headache: new hope for a dreadful disease?

Chronic cluster headache (CCH) is one of the most painful primary headaches. A small percentage of CCH become intractable (iCCH) and is refractory to the majority of preventing drugs. Various invasive and sometimes destructive procedures have been tempted to help these patients, but none gave satisfactory results for the long term. Hypothalamic deep-brain stimulation (hDBS) has recently raised expectations with an average improvement of 50 to 70%, but is not a riskless procedure. Harmless methods were therefore warranted, and in this perspective occipital nerve stimulation (ONS) trials were undertaken. Up to now, nearly 38 iCCH patients benefited from ONS in the available literature and the technique appears to give results similar to hDBS, having the advantage to have much milder side effects. The mechanism by which ONS is efficient in iCCH remains unknown but preliminary results of neurophysiological and imaging studies suggest ONS is just a symptomatic treatment which does not act on the disease generator. We would however advocate ONS as first choice alternative therapy in iCCH.