BACKGROUND: Paroxysmal stabbing or ice pick-like headaches located in the extratrigeminal areas are not uncommon in clinical practice. However, clinical characteristics of acute stabbing headaches initially presented in the retroauricular regions have rarely been described in detail. METHODS: Among the subjects referred to Hallym University Medical Center, due to the acute-onset stabbing headache during the last five years, sixty-six consecutive patients in which stabbing symptoms were confined to the retroauricular regions at initial presentation were prospectively included. RESULTS: All patients were neurologically and otologically considered to be normal at the initial presentation. The nature of pain lasted for short intervals of time, and were moderate to severe in intensity for most patients. All but five ran a self-limited benign course, recovering completely in 3 days to 30 days, mostly within 2 weeks. During the clinical course, subsequent Bell's palsy developed in 2 patients, and otic or cervical zoster lesions followed in three cases. Those among the 61 subjects with unknown etiology, the headaches were preceded by flu-like symptoms or upper respiratory tract infections in 21 subjects (34%) and physical, mental or both kinds of stresses were reported in 15 subjects. CONCLUSIONS: Most of paroxysmal stabbing headaches confined to the retroauricular regions are very short-lasting in nature, and show self-limiting and benign course, suggesting lesser occipital neuralgia or a variant of primary stabbing headache involving cervical nerves. However, the possibility of subsequent zoster infection or peripheral type of facial palsy should be considered, even though neurologically not remarkable at initial presentation.