Abstract

Background: Subcutaneous occipital nerve stimulation (ONS) has emerged as a neuromodulatory option for patients with chronic, medically intractable headache disorders, yet its clinical effectiveness and safety remain debated.

Methods: A narrative, non-systematic review (PubMed, Embase, Cochrane Library; search date 21 April 2025) was performed using combined terms for “occipital nerve stimulation” and refractory headache entities. After duplicate removal and staged screening, 77 peer-reviewed human studies were retained for qualitative synthesis.

Results: Across study designs, ONS produced clinically meaningful improvement in 35.7–100 % of patients, with a pooled responder rate of 57.3 % in chronic cluster headache and sustained benefit in >40 % of chronic migraine cases over ≥4 years. In occipital neuralgia and short-lasting unilateral neuralgiform attacks, 63–100 % response was observed. Randomised data show an additional mean reduction of 2.6 moderate-to-severe headache days per month versus sham in chronic migraine, and comparable efficacy at both high- and low-intensity stimulation in cluster headache. Despite therapeutic gains, adverse events were frequent: overall complication rates reached 66 %, driven by lead migration (2–60 %), infection (2–24 %) and premature battery depletion (up to 70 %), often necessitating revision surgery. Long-horizon modelling nevertheless suggests ONS can become cost-effective within one year for refractory cluster headache owing to reduced drug use and productivity loss.

Conclusions: Current evidence supports ONS as a valuable, albeit invasive, symptomatic therapy for selected patients with refractory headache syndromes. High hardware-related morbidity underscores the need for purpose-built implants, standardised surgical protocols and robust, blinded trials to refine patient selection and define long-term risk–benefit and cost-utility profiles.