The Untold Story of Occipital Nerve Stimulation in Patients With Cluster Headache: Surgical Technique in Relation to Clinical Efficacy

Objectives: Approximately one in every 1000 adults experiences cluster headache (CH). Although occipital nerve stimulation (ONS) appears encouraging in treatment for most patients with refractory CH, some patients do not reach adequate pain relief with ONS. A reason for failure of ONS might be anatomical variations and different surgical approaches. Therefore, an extensive literature analysis was performed, and cadaveric experimentation was combined with our clinical experience to provide a standardized proposal for ONS and obtain optimal management of patients with refractory CH. Materials and Methods: Data from 36 articles published between 1998 and 2023 were analyzed to retrieve information on the anatomical landmarks and surgical technique of ONS. For the cadaveric experimentation (N = 1), two electrodes were inserted from the region over the foramen magnum and projected toward the lower third of the mastoid process. Results: The existence of multiple approaches of ONS has been confirmed by the present analysis. Discrepancies have been found in the anatomical locations and corresponding landmarks of the greater and lesser occipital nerve. The surgical approaches differed in patient positioning, electrode placement, and imaging techniques, with an overall efficacy range of 35.7% to 90%. Conclusions: Reports on the surgical approach of ONS remain contradictory, hence emphasizing the need for standardization. Only if all implanting physicians perform the ONS surgery using a standardized protocol, can future data be combined and outcomes compared and analyzed.