Occipital nerve stimulation (ONS) continues to be investigated for the treatment of refractory chronic migraine. Results from case series and from prospective, sham-controlled clinical trials remain inconclusive regarding the efficacy of ONS for migraine treatment. Safety and implantation techniques require improvements since rates of lead migration, infection, and persistent stimulator-related pain continue to be high. Existing data justify further ONS trials with carefully chosen primary outcome(s), adequate statistical power, and improved surgical techniques.