Cluster headaches (CH) are excruciating and cause significant medical, economic and social impairment, especially when refractory to medical therapies. While inconsistent results have been reported with many neuromodulatory approaches, a randomized sham-controlled study of sphenopalatine ganglion (SPG) stimulation
reported significant pain relief in 67% of patients with stimulation during acute attacks and a >50% reduction in attack frequency in 43% of patients. Therefore, the device has received a CE mark, but is not currently approved by the US FDA. Given SPG stimulation’s promise and safety, an expert consensus was published providing details of the appropriate organizational structure for implanting centers, patient selection (defining refractory CH and treatment inclusion/exclusion criteria), preoperative examination, imaging, target determination, intra- and peri-operative management (anesthesia, surgical technique, imaging, test stimulation), and post-operative management and programming. The expert panel proposes future long-term evaluations of SPG stimulation efficacy and safety in drug-refractory CH.