Vagus nerve stimulation (VNS) is gaining increasing popularity and credibility as a treatment option for patients with intractable epilepsy. VNS is a relatively recent innovation, however, and like many other incipient developments, it has engendered a number of unresolved controversies and perplexities. Limitations in our current understanding of how VNS works lie at the crux of these uncertainties. In this article, we present our clinical experience with VNS and review the fundamental issues which remain unsettled, such as the mechanism of VNS action, the factors underlying variability in patient outcome, and the selection of ideal candidates for VNS therapy. Although many enigmas persist, VNS has proven to be a safe, feasible, and potentially effective method of reducing seizures in select patient populations. It offers several advantages over extant treatments and, as a result, holds much promise for future therapy of medically refractory epilepsy.