Persistent occipital neuralgia can produce severe headache that is difficult to control by conservative or surgical approaches. We now describe retrospectively a series of 6 patients with severe occipital neuralgia who failed conservative and interventional therapies, including oral antidepressants, membrane stabilizers, opiates and traditional occipital nerve blocks. This group then underwent occipital nerve blocks using the botulinum toxin type A (BoNT-A) 50U for each block (100U if bilateral). Significant decreases in pain VAS scores and improvement in Pain Disability Index (PDI) were observed at four weeks follow-up in 5 out of 6 patients following BoNT-A occipital nerve block, while the sixth patient did not improve. The mean VAS score changed from 8 ±1.8 (median score of 8.5) to 2 ± 2.7 (median score of 1), while Pain Disability Index (PDI) improved from 51.5±17.6 (median 56) to 19.5±21 (median 17.5).The duration of the pain relief averaged 16.3 ±3.2 weeks (median 16) compared with an average of 1.9 ± 0.5 weeks (median 2) for diagnostic 0.5% bupivacaine block. Following block resolution the average pain scores and PDI returned to similar levels as before BoNT-A block. Conclusions: BoNT-A occipital nerve blocks provided a much longer duration of analgesia than diagnostic local anesthetics. The functional capacity improvement measured by PDI was profound enough in majority of the patients to allow patients to resume their regular daily activities.