Background: Fractures of the paracondylar process of the occipital bone may cause headshaking, neck pain and neurologic deficits. The condition is being recognized more frequently with increasing availability of computed tomography. However, to date only limited information is available as to presentation, treatment, surgical approach and outcome. Objectives: To describe the clinical signs, imaging findings, treatment, surgical approach and outcome in three horses diagnosed with paracondylar process fracture. Study Design: Retrospective case series. Methods: Clinical records and diagnostic images of affected cases were reviewed, with informed owner consent. Results: Two cases with ventral fractures presented with neck pain and stiffness, one of which had a primary complaint of poor performance while the other also displayed headshaking and other behavioural changes. A third case with a more dorsal fracture presented with acute facial nerve paralysis. Diagnosis was by computed tomography in all cases. Conservative management resulted in improvement in all cases with available follow-up, although mild residual neurologic deficits remained in one. Repeated recurrence of clinical signs after prolonged periods of remission necessitated surgical removal in one case, which was readily accomplished with the aid of ultrasound guidance, and led to rapid resolution of clinical signs without significant post-operative complications. The surgical approach is described. Main Limitations: Limited follow-up was available for some cases. Conclusions: Paracondylar process fracture should be considered as a differential diagnosis for headshaking, neck pain, poor performance and facial paresis, and is a justification for performing computed tomography in such cases. A multi-disciplinary approach is beneficial due to the potential for orthopaedic, neurologic, ophthalmologic and behavioural clinical signs, with additional need for expertise in diagnostic imaging and pain management. Surgical fragment removal should be considered in cases that do not respond adequately to conservative management.