Purpose: Malignant head and neck paragangliomas (MHNPs) are rare and occur in 6%�19% of all HNPs. We sought to identify predictors of survival and compare efficacy of treatment modalities to inform management of this rare disease. Materials and methods: We performed a retrospective cohort study of MHNP cases in the National Cancer Institute Surveillance Epidemiology and End Results database (SEER) from 1973 to 2009. We identified 86 patients with MHNP who had documented regional or distant tumor spread with a median follow-up of 74months. We used Cox proportional hazard models to assess the significance of demographic factors and treatment on five-year overall survival. Results: The most common treatment was surgery alone (36.0 %), followed by surgery with adjuvant radiation (33.7%). Five-year overall survival was 88.1% for surgery alone and 66.5% for adjuvant radiation (p=0.2251). In univariate analysis, regional (vs. distant) spread (HR 0.23, p<0.0001), surgery alone (hr 0.29, p><0.0001) and primary site in the carotid body (hr 0.32, p="0.006)" conferred significant survival advantage whereas age>50 (HR 4.04, p<0.0001) worsened survival. regional (vs. distant) spread (hr 0.42, p="0.046)" and age>50 (HR 2.98, p=0.005) remained significant in multivariate analysis. In patients with regional-only disease, five-year overall survival was 95.4% for surgery alone compared to 75.6% for surgery with radiation (p=0.1055). Conclusions: This is the largest and most contemporary series of MHNP patients. Age and tumor stage are significant factors in predicting survival. Surgical resection significantly improves survival outcomes. From this analysis, the value of adjuvant radiation is not clear.