The craniovertebral junction (CVJ) is a challenging region for the management of metastases. Although metastases to the CVJ are rare, the incidence is increasing as the prognoses of cancer patients continue to improve. In this review, the epidemiology and natural history are reviewed. Key features on radiographic studies are discussed so that the clinician can assess the optimal treatment paradigm for these patients. Lastly, we discuss which patients are should be considered for surgery and which patients should just have radiation without operative intervention.