To emphasize the need for imaging and consideration for alternative etiologies in patients with occipital neuralgia presenting with uncommon symptomology.

To date, occipital neuralgia has been associated with cervical lesions and cervical stenosis making interventions such as occipital nerve blocks, cervical epidural injections, neuropathic pain agents and physical therapy effective therapeutic options. We report a case of right sided occipital neuralgia in which imaging confirmed a right occipital bone lesion eventually leading to the diagnosis of multiple myeloma.

A 65-year-old woman with no known medical history presented with sharp shooting pain radiating from the right occiput upward for the last 3 months. She additionally described neck pain radiating down the right arm with a patchy distribution of numbness associated with paresthesias in the right arm. She denied any weakness, gait imbalance, or bowel/bladder dysfunction. Her physical exam was significant for right occipital notch tenderness and hyperreflexia. Due to the new onset of her symptoms, age, and unusual features, a MRI brain with and without contrast, MRA head/neck and MRI cervical spine were ordered.

The phenotypic spectrum of occipital neuralgia shows significant clinical variability, but persistent new focal neurologic deficits should raise suspicion for alternative pathology.