Introduction Occipital nerve stimulation (ONS) appears a promising treatment for refractory headaches. The procedure is invasive and response rates vary between studies. Identification of clinical predictors of outcome is therefore of importance.

Aim To prospectively assess the efficacy of ONS in a cohort of intractable headache patients and identify clinical predictors of response.

Methods 165 patients undergoing ONS at a single centre were studied. Headache load was calculated at baseline and final follow-up. A positive response was defined as a 30% reduction in headache load. A multivariate logistic regression analysis was carried out to identify predictors of outcome.

Results Patient group was highly refractory at baseline. At a mean follow up of 40 months the response rate of the group was 50%. Clinical factors identified with an increased likelihood of response were co-existent chronic migraine and chronic cluster and the presence of non-headache related pain disorders. Occipital pain was associated with a reduced likelihood of response. Adverse event rates were favourable.

Conclusion ONS is a potentially useful and safe treatment in refractory chronic headache disorders. The presence of multiple pain syndromes appears associated with increased likelihood of response and presence of occipital pain with a reduced likelihood.