1. 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 .
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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
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