TMS, or transcranial magnetic stimulation, is an alternative therapy for pain (including migraine headache) and some mental illnesses. It involves transmitting a magnetic pulse onto the scalp, which induces currents within the brain. This electric field activates neurons in areas of the brain that are underactive; as of now, TMS can reach depths of about 1.5 to 3 cm below the skull surface. There are many different types of TMS, but they all can target specific areas of the brain, depending on where the magnetic pulse is administered. First developed in 1985, TMS was originally, and continues to be, used for clinical trials. It is used to measure motor conduction times and assess neural excitability.
What are the types of TMS?
The two main categories of TMS are sTMS and rTMS. sTMS refers to single-pulse TMS. This means that only a single magnetic pulse is transmitted. With rTMS, or repeated-pulse TMS, a train of pulses is administered. Sometimes a pair of single pulses is administered, and this can be referred to as paired-pulse TMS or ppTMS.
Another common type of TMS is theta burst stimulation, or TBS. During theta burst stimulation, the magnetic pulse is delivered at a specific frequency that mimics brain waves. This type of TMS is sometimes preferred because it promotes neuroplasticity. It is also often referred to as Express TMS because administration takes only about 3 minutes, whereas typical 10-Hz rTMS methods can take over 30 minutes.
Typically, TMS is done in a clinical office and administered by a professional. This is necessary for most types of TMS, including rTMS and theta burst. There are private clinics like Bespoke Treatment that administer TMS in a safe and comfortable environment. However, personal sTMS devices are now available. These mobile neuromodulatory devices can be self-administered at home.
What does TMS treat?
TMS has been used in clinical settings to monitor brain activity for over 30 years and is an FDA-cleared treatment for many types of mental illnesses as well as pain management. It is most often used as an alternative therapy for Major Depressive Disorder and bipolar depression that is resistant to standard forms of treatment. Patients with depression who have tried various medications like SSRI’s are often eligible to have TMS therapy covered by health insurance. It is still recommended to resume psychotherapy or other social therapies during and after TMS treatment. TMS can also be effective in treating anxiety, PTSD, OCD, and smoking cessation for some patients.
There is also evidence that TMS can effectively treat migraines. sTMS has been shown to be an effective treatment for acute migraines with aura when administered at the onset of aura. It is also an FDA-cleared treatment for migraine without aura, recommended to be administered at the onset of a migraine attack. rTMS also shows promise as a preventative treatment for chronic migraine. Repeated administration of rTMS resulted in a decline in migraine frequency, duration, and intensity.
The first device which was FDA cleared for migraine treatment was an sTMS device, discussed further here. It was initially FDA cleared for the acute treatment of episodic migraine with aura in adults in December 2013. It then received FDA clearance for both acute and preventive treatment of migraine in adults in 2017. This clearance was then expanded to the acute and preventive treatment of migraine in children 12 years of age and older in February 2019. Prior models included the Spring TMS and sTMS mini. The newest model, SAVI, is currently the only FDA cleared device for both the acute and preventive treatment of migraine in adults and children 12 years of age or older. Since the device is used acutely and preventively, the FDA approved it for a maximum of 17 pulses per day.
The user holds the device against the back of the head, and presses a button to release a very short magnetic pulse at the onset of aura or a migraine attack with or without aura. The magnetic pulse delivers a fluctuating magnetic field which induces a mild electric current through the skull and onto the surface of the occipital cortex (visual cortex) of the back part of the brain. This modifies the electrical excitability and hyperactivity of the cortical neurons to block or prevent the onset of a migraine from evolving to a full-blown migraine. The device stops cortical spreading depression, which is suspected to be the basis of migraine aura in the occipital cortex. It is also suspected to interfere with thalamocortical pain pathways that are normally activated during a migraine.
The most common side effects were mild and brief light-headedness/dizziness, tingling over the back of the head where treatment is performed, brief tinnitus (ringing in ears), nausea, and muscle spasm. You should not use this device if you have a cardiac pacemaker, vagus stimulator (VNS) or other implanted neurostimulator, implanted cardioverter defibrillator (ICD) or any implanted medical device that stimulates the body or uses any signal from the body. It is also suggested that patients with implants affected by a magnetic field should not use this device. Examples of such implants include aneurysm clips or coils, cochlear implants, cerebral spinal fluid shunts, bullets or pellets lodged in the head or upper body, metal plates, screws, staples or sutures in skull, neck, shoulders, arms or hands, and facial tattoos with metallic ink. Dental implants, fillings or other dental appliances are okay to use the device.
Acute migraine treatment consists of 3 sequential pulses (early) at the onset of a migraine (aura or pain). Then wait 15 minutes. If needed, treat with an additional 3 pulses. Then wait another 15 minutes. If needed, treat with an additional 3 pulses. Studies reported that 39% of patients were pain free at 2 hours.
Migraine prevention treatment consists of 4 pulses twice daily. This is performed by giving 2 consecutive pulses, waiting 15 minutes, and then repeating 2 consecutive pulses. Studies reported that 46% of patients had a greater than 50% reduction in monthly headache days and averaged approximately 3 less migraine days per month.
The use of non-medication options for migraine such as TMS can help to avoid common side effects of standard abortive pills such as NSAIDs and triptans, and can help to avoid rebound headache (medication overuse headache).
What are the side effects of TMS?
TMS is FDA-cleared and it is a very safe treatment option for pain and mental illness. In general, the most commonly reported side effect is light headedness or dizziness directly after treatment that fades quickly. Most patients describe the actual TMS administration to be mildly uncomfortable, and report feeling a tapping sensation on the scalp. Additionally, TMS cannot be administered if you have any kind of metal implants or a high risk of seizure.
Occasionally, Virtual Headache Specialist will allow guest bloggers to write or contribute to an article on a migraine related topic. The bulk of this article was written by Ben Spielberg, M.S. with edits and contributions (especially the sTMS migraine treatment discussion) by myself. Ben Spielberg is the Founder and CEO of TMS & Brain Science, a brain health center dedicated to cutting-edge solutions for treatment-resistant depression and many other mental health needs. With his team of passionate mental health specialists, Ben has been a leader in bringing TMS, neurofeedback, and ketamine therapy to Southern California.
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