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Effective occipital nerve stimulation during pregnancy in a cluster headache patient Dear Editor, Cluster headache is a rare primary headache disorder characterized by attacks of excruciating, intermit-ting short-lasting unilateral temporal or orbital pain (1). Cluster headache in pregnancy can be difficult to treat because of a limitation in treatment options. The only acute treatment that is not harmful during pregnancy is oxygen inhalation. However, this is effective in about 60% of patients (2,3). Sumatriptan can be considered , but is not recommended during pregnancy due to a lack of controlled prospective studies about pre-natal toxicity. However, a retrospective study of over 600 women reported a lower rate of congenital malfor-mations in children of women who had been using sumatriptan during their pregnancy than in the average population and another observational study reported no signal of teratogenicity associated with major birth defects for sumatriptan (4,5). The available prophylac-tic drug treatments are not recommended during the pregnancy because of a lack of controlled prospective studies about their prenatal toxicity (6). Here, we report a possible alternative prophylactic cluster headache treatment during pregnancy. A 32-year-old woman, suffering from cluster headache since the age of 25 years, was diagnosed with medically intractable chronic cluster headache with an average of nine attacks per week. She participated in our ongoing study on occipital nerve stimulation (ONS) in chronic cluster headache as prophylactic treatment (7). After the ONS implantation, her attack frequency dropped to once per week and the pain intensity of the remaining attacks diminished as well. Having at first decided to refrain from pregnancy due to the lack of possible attack treatment, she brought up her wish to become pregnant 18 months after ONS implantation. At that time, she used sumatriptan SC and oxygen as acute treatment and ONS as prophylac-tic treatment. Shortly thereafter, she indeed became pregnant. During the first 3 months of her pregnancy she refrained from sumatriptan SC and treated the remaining cluster headache attacks successfully with oxygen (9 L/min). An ultrasound after 10 weeks pregnancy did not show any foetal abnormalities. During the second trimester she only needed sumatriptan SC once, the attack frequency had dropped to one attack per 2 weeks. Another ultrasound after 20 weeks of pregnancy also showed no abnormalities. During the last trimester, attack frequency further dropped to one attack per 6 weeks, for which oxygen remained effective. At 35 weeks of pregnancy she did not recharge …