Neurostimulation in chronic cluster headache

About 1% of all chronic cluster headache patients become intractable (iCCH; ie, they are refractory to adequate regimens of all established preventive drugs). Various lesional interventions have been attempted in these patients, none with lasting benefits. In recent years, nondestructive neurostimulation methods have raised new hope. Hypothalamic deep brain stimulation (hDBS) acts rather rapidly and has durable efficacy, but it is not without risk. Occipital nerve stimulation (ONS) was studied in two trials that included 17 iCCH patients. Clinical efficacy was found to be very satisfactory by most patients and investigators. Although slightly less efficacious than hDBS, ONS has the advantage of being harmless and reversible. At this stage, it should be the preferred first-line invasive therapy for iCCH. Recent case reports mention efficacy of supraorbital and vagus nerve stimulation. Whether these neurostimulation methods have a place in the management of iCCH patients remains to be determined.