1. Background 2. Methods Figure 1: MRI of Patient 3. Results Occipital Neuralgia after Metastatic Tonsilar Squamous Cell Carcinoma Lauren Green, D.O, R.D ; Ceren Ugurlu, M.D; Soma Sahai-Srivastava, M.D University of Southern California Department of Neurology, Los Angeles, California, USA 1. Background 2. Methods Figure 1: MRI of Patient Occipital neuralgia (ON) is characterized by paroxysms of pain occurring within the distribution of the greater and/or lesser occipital nerves. Secondary causes include ; Closed head injury, Direct occipital nerve trauma, Neuroma formation Upper cervical root compression The majority of patients have no demonstrable lesion. Most articles suggest prevalence in the general population of between 0.4% and 4%, other reports from specialty clinics report higher rates, as high as 16%. ON has been reported as the only symptom in a patient with a foramen magnum meningioma. Ballesteros-Del Rio et al. reported a case of ON Secondary to Greater Occipital Nerve Schwannoma. Clavel et al. reported a case of a 78-year-old woman suffering from right ON with imaging demonstrating an irregular bone mass in the C-2 vertebral body. There have been no reported cases of occipital neuralgia due to metastatic lesion affecting the occipital nerve. This is a case report and review of literature. 3. Results The patients is a 62-year old right handed male with metastatic carcinoma who began experiencing posterior headaches 1 year ago.  Symptoms; He was aphonic due to removal of his larynx and wrote all responses.  The pain was located in the right occipital region and radiated into the frontotemporal area and right ear. It was constant, ranging between 2-9/10 on the pain scale. A major concern was for the patients’ quality of life. The pain bothered him more than the disease itself. The patients’ past medical history is significant for TSCC with metastasis to the regional lymph nodes, pharynx, larynx, base of tongue, and thyroid lobe. His cancer was treated with multiple surgeries, radiation, and chemotherapy.  Imaging done 3 months prior to our clinic presentation was reported normal.  MRI was repeated with a time interval of 3 months and showed skull base metastasis and enhancing tissue extending into the right perimedullary cistern with mass effect on the right side of the medulla. A T2 hyperintensity was noted in the C2 nerve root. Physical exam was significant for tenderness over the affected nerve and ON was confirmed by complete resolution of pain with occipital nerve block. Treatment; Conservative management continued with nortriptyline and physical therapy. Radiofrequency ablation (RFA) of C2 nerve root was done because the occipital nerve block resolved the pain. The patient remains pain free two months post RFA. Chemotherapy with Erbitux for new metastatic lesions was resumed and a follow up PET scan showed interval marked response to treatment . Copy and paste your text content here, adjusting the font size to fit 4. Conclusion One case is described in which occipital neuralgia developed after squamous cell carcinoma metastasized to the C2 nerve root.   We hypothesize that the lesion triggered new onset occipital neuralgia. ON with a history of head and neck cancer should be imaged with contrast to evaluate c2/3 area. For patients with ON secondary to cancer consider early RFA for pain improvement and better quality of life. More research is necessary to confirm our findings. 5. References Greenberg, Harry S., Michael DF Deck, Bhadrasain Vikram, Florence CH Chu, and Jerome B. Posner. "Metastasis to the base of the skull clinical findings in 43 patients." Neurology 31, no. 5 (1981): 530-530. Weiner, Richard L., and Kenneth L. Reed. "Peripheral neurostimulation for control of intractable occipital neuralgia." Neuromodulation: Technology at the Neural Interface 2, no. 3 (1999): 217-221. Ziegler DK & Murrow RW. Headache. In:Joynt R, ed. Clinical Neurology,Vol. 2,Philadelphia:JB Lippincott,1988, pp. 1 35. Barna, S. T. E. V. E. N., and M. A. L. I. H. A. Hashmi. "Occipital neuralgia."Pain Management Rounds 1, no. 7 (2004). Ballesteros-Del Rio, Beatriz., Ares-Luque, Adrian, et al. Occipital (Arnold) Neuralgia Secondary to Greater Occipital Nerve Schwannoma. Headache: The Journal of Head and Face Pain. Vol.43, Issue7. July 2003: pages 804–807. Arasil, Ertekin., Erdem, Atilla., Yüceer, Nurullah.. Osteochondroma of the Upper Cervical Spine: A Case Report. Spine. February 1996. Vol.21, Issue 4:p516-518. Chou, Larry H., and David A. Lenrow. "Cervicogenic headache." Pain Physician5, no. 2 (2002): 215-225. Ehni, George., Benner, Benjamin. Occipital neuralgia and the c1-2 arthrosis syndrome. Journal of Neurosurgery. November 1984. Vol. 61, No 5: Pages 961-965.  Clavel, Manuel.,Clavel, Pablo. Occipital neuralgia secondary to exuberant callus formation. Journal of Neurosurgery. December 1996 , Vol. 85, No. 6: Pages 1170-1171. Kim, Nam-Hee, Seung-Yeob Yang, Joon-Bum Koo, and Sang-Wuk Jeong. "Occipital neuralgia as the only presenting symptom of foramen magnum meningioma." Journal of Clinical Neurology 5, no. 4 (2009): 198-200. Anthony, Michael. Headache and the greater occipital nerve. Clinical Neurology and Neurosurgery. Volume 94, Issue 4, (December 1992):279-300.