From Standard Injection Protocols to Precision TargetingDr. Hsin-Hung Chen Discusses Botulinum Toxin Treatment for Migraine at TSAPS 2026
From Standard Injection Protocols to Precision Targeting
Dr. Hsin-Hung Chen Discusses Botulinum Toxin Treatment for Migraine at TSAPS 2026
Image 1: Dr. Chen speaking at the conference
Dr. Hsin-Hung Chen spoke at the OSAPS 2026 and 32nd TSAPS International Annual Meeting, held in Taipei, Taiwan, on September 12–13, 2026.
His presentation, titled “Therapeutic Applications of Botulinum Toxin Type A in Migraine Management,” examined how botulinum toxin type A may be used in the management of chronic migraine.
The presentation covered the mechanisms of migraine, evidence from the PREEMPT clinical program, common peripheral nerve trigger sites, patient evaluation, injection safety, and the transition from standardized injection patterns toward more individualized treatment planning.
Image 2: English presentation title slide
Image caption: Dr. Hsin-Hung Chen presented on the therapeutic applications of botulinum toxin type A in migraine management.
Migraine Is More Than a Vascular or Muscular Condition
Migraine was once viewed primarily as a vascular disorder. Current research, however, suggests that its underlying mechanisms involve complex interactions between the central and peripheral nervous systems.
In some patients, irritation or sensitization of specific peripheral sensory nerves may initiate or perpetuate the migraine pain cycle.
Although two patients may both be diagnosed with migraine, their pain patterns may be very different. Some experience pain beginning around the forehead, eyebrows, or orbital area. Others feel pain primarily in the temples or at the back of the head, sometimes radiating toward the scalp or forehead.
Identifying where the pain begins, how it spreads, and what triggers it can provide important information for further evaluation.
Botulinum Toxin Type A Does More Than Relax Muscles
Botulinum toxin is widely known for reducing muscle activity and softening dynamic wrinkles. Its therapeutic role in migraine management, however, is not limited to muscle relaxation.
Botulinum toxin type A may inhibit the release of certain neurotransmitters involved in pain transmission and reduce peripheral nerve sensitization. This may help decrease the continued transmission of pain signals from peripheral trigger sites to the central nervous system.
The objective is therefore not simply to weaken a particular muscle. Treatment aims to reduce repeated pain signaling and, in appropriate patients, decrease the frequency and severity of chronic migraine attacks.
The PREEMPT Program Established an Evidence-Based Foundation
During the presentation, Dr. Chen reviewed the PREEMPT clinical program, one of the most important bodies of research supporting the use of botulinum toxin type A for chronic migraine.
The program included 1,384 patients across 122 study sites worldwide. It consisted of a 24-week double-blind, placebo-controlled phase followed by a 32-week open-label phase.
The PREEMPT protocol uses a standardized pattern of fixed injection sites, with additional areas considered according to the patient’s pain distribution.
Study results demonstrated a significant reduction in the number of headache days among patients receiving treatment. Improvements were also observed during continued treatment through the follow-up period.
The PREEMPT program remains an important evidence-based foundation for botulinum toxin treatment in patients with chronic migraine.
Moving Toward Individualized Pain Mapping
While standardized protocols provide an important clinical framework, not every patient experiences migraine in the same location or pattern.
Migraine assessment is therefore moving toward a more individualized approach that considers the patient’s actual pain distribution and possible peripheral nerve trigger sites.
Common areas evaluated may include:
The supraorbital and supratrochlear nerves in the forehead and brow region
The zygomaticotemporal and auriculotemporal nerves in the temporal region
The greater and lesser occipital nerves in the posterior scalp and neck region
This does not mean that treatment is simply administered wherever the patient reports pain. The physician must combine the patient’s history, pain pattern, physical examination, tactile findings, and anatomical knowledge to identify the areas most likely to be involved.
Three Essential Steps Before Migraine Treatment
Image 3: Original English Patient Evaluation Process slide
Dr. Chen summarized the pre-treatment assessment process in three stages.
Gate 1: Comprehensive History
The first step is to understand the patient’s headache pattern in detail.
Important information may include:
Frequency and duration of headache attacks
The location where pain first begins
The direction in which the pain spreads
Possible triggers
Associated symptoms
Previous treatments and their results
Keeping a migraine diary can be helpful. Patients may record the date of each attack, pain location, severity, duration, potential triggers, associated symptoms, and medication use.
Gate 2: Physical Examination and Tactile Mapping
The second stage involves physical examination and tactile mapping of possible trigger points.
The physician uses gentle pressure to examine areas associated with peripheral sensory nerves. If pressure over a particular area reproduces the patient’s familiar pain, tenderness, or radiating sensation, the finding may help identify a clinically relevant trigger site.
Dr. Chen emphasized that tactile mapping is not merely a routine step. It can provide valuable information for locating the possible source of peripheral nerve-related pain.
Gate 3: Pre-Procedure Safety Check
Before treatment, the physician must also evaluate existing conditions that may affect treatment safety or outcomes.
These may include pre-existing eyelid or eyebrow ptosis, facial asymmetry, reduced neck strength, or other anatomical and functional concerns.
The findings may influence the selection of treatment areas, injection depth, and dosage.
Anatomical Knowledge Is Essential for Safety
The forehead, temples, posterior scalp, and neck each contain different nerves, muscles, and surrounding structures. Treatment techniques should therefore not be identical across every region.
In the forehead and brow area, physicians must consider eyebrow position and the function of the muscles that elevate the brows. Inappropriate placement may increase the risk of brow heaviness or temporary eyebrow ptosis.
The temporal region requires an understanding of the relationship between sensory nerves and branches of the facial nerve.
Treatment of the posterior scalp and neck must also account for nerve depth, muscle thickness, and the patient’s baseline neck condition. Overly broad treatment or inappropriate dosing may lead to temporary neck soreness or weakness.
Successful treatment therefore depends not only on the selected medication but also on accurate anatomical assessment and careful technique.
More Injection Sites Do Not Necessarily Mean Better Results
Migraine pain may involve several areas, but a greater number of injection sites or a higher dose does not automatically produce a better outcome.
When a physician can identify clinically relevant trigger areas through detailed history-taking and tactile mapping, treatment can be focused on the regions most closely associated with the patient’s symptoms.
The objective of individualized treatment is not to abandon evidence-based protocols. Instead, it is to apply established treatment principles while considering each patient’s unique pain distribution, anatomy, and safety profile.
Communication Is Part of the Treatment
Possible adverse effects of botulinum toxin injections may include injection-site discomfort, bruising, local soreness, temporary asymmetry, eyebrow or eyelid position changes, and temporary neck soreness or weakness.
Although many of these effects are temporary, they may still affect a patient’s daily activities and confidence.
Before treatment, patients should understand:
The objective of the treatment
The expected degree of improvement
Possible adverse effects
The temporary nature of the treatment effect
Individual differences in treatment response and duration
Whether medication or other specialist treatment may still be required
Clear communication helps patients develop realistic expectations and is an important part of treatment safety.
Patient-Centered Migraine Management
Migraine may involve the central nervous system, peripheral nerves, muscle tension, lifestyle factors, and multiple triggers. There is therefore no single treatment strategy that is appropriate for every patient.
Botulinum toxin type A may be considered for selected patients with chronic migraine. However, the decision to proceed with treatment, the areas to be treated, and whether other therapies should be combined must all be determined through an individualized medical assessment.
According to Dr. Chen, effective migraine management should begin with the patient’s actual experience of pain. A combination of detailed history-taking, anatomical knowledge, tactile mapping, and safety evaluation may help physicians develop a more precise and appropriate treatment strategy.
Through ongoing academic exchange and clinical discussion, Dr. Chen hopes to increase awareness of peripheral nerve-directed assessment and promote a more patient-centered approach to migraine management.
Medical Disclaimer
Migraine is a complex neurological condition, and headaches may also be associated with other medical disorders. This article is provided for medical education and academic exchange only and does not replace professional diagnosis or treatment.
The suitability of botulinum toxin treatment, injection sites, dosage, and treatment intervals must be determined by a qualified physician based on each patient’s symptoms, medical history, and physical condition.
About the Author
Dr. Hsin-Hung Chen
Dr. Hsin-Hung Chen is a board-certified plastic surgeon currently practicing at Jeunesse Aesthetic Plastic Clinics in Taipei and Taichung, as well as Chia Fei Ya Aesthetic Clinic in Taipei. He has extensive clinical experience in aesthetic plastic surgery, craniofacial anatomy, and the evaluation and surgical treatment of migraine.
Dr. Chen is an active member of the Migraine Surgery Association. He has also completed advanced clinical training in Cleveland, United States, where he studied migraine surgery, facial rejuvenation, and rhinoplasty under Professor Bahman Guyuron, a pioneer in modern migraine surgery.
Through continued international academic exchange and clinical practice, Dr. Chen is committed to providing comprehensive and individualized evaluation and treatment options for patients affected by migraine.
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