An increasingly procedural discipline.

Performed with the full PREEMPT protocol — 155 units across 31 fixed sites, with follow-the-pain supplementation where indicated — repeated every 12 weeks. Protocol compliance matters: incomplete or improvised injection patterns are one of the most common reasons patients are told Botox 'didn't work' for them.

Greater and lesser occipital nerve blockade with local anesthetic, with or without steroid. Used for rescue during a prolonged attack, to break a cycle after medication overuse withdrawal, and as a diagnostic step when occipital nerve involvement is suspected.

Transnasal delivery of anesthetic to the sphenopalatine ganglion — a well-tolerated, needle-free option that targets the autonomic relay driving cluster attacks, hemicrania, and some post-dural-puncture headaches.

Targeted injection of cervical, trapezius, and pericranial myofascial trigger points that maintain a headache pattern long after the original trigger has resolved. Often paired with a nerve block in the same visit.

Peripheral trigeminal branch blocks for focal frontal, periorbital, or temporal pain — frequently valuable after concussion or head injury where pain localizes to a specific nerve distribution.

In-office intravenous protocols — DHE, magnesium, valproate, antiemetic and neuroleptic regimens, steroid bridges — designed to end a prolonged attack or carry a patient through withdrawal from overused acute medication, without an emergency department visit.