rTMS: How Does It Work?

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By Dr. David Woo - November 28, 2022

Repetitive transcranial magnetic stimulation (rTMS) is a painless, medication-free therapy that is proven effective at treating certain mental health conditions, including depression, anxious depression, and OCD. What makes rTMS unique, is that it’s non-invasive and proven to be effective for individuals who are considered treatment-resistant (people who have not seen results from standard therapies, like medication).(1,2)

What Is the Difference between TMS and rTMS?

rTMS is often referred to as TMS. Clinically, there is no difference between rTMS and TMS, and all types of TMS that are used for the treatment of depression and OCD are considered rTMS.

How Does rTMS Work?

TMS works with the electrical activity in the brain to stimulate brain cells (neurons) to release neurotransmitters (chemical messengers in the brain) and improve connectivity between neurons.

TMS uses magnetic coils that administer repeated magnetic pulses (similar to those used in an MRI machine). These repeated magnetic pulses form a magnetic field that then influences the brain’s electrical activity to relieve symptoms.(3,4)

rTMS Influences Specific Regions of the Brain to Relieve Symptoms

TMS is directed at certain areas of the brain (for example, the prefrontal cortex) that are associated with mood disorders like depression.(5,6) A recent study published in May 2022 shows that when rTMS is applied to the prefrontal cortex for depression treatment, and neurons in this part of the brain are stimulated, this leads to stimulation of other brain regions associated with depression. This study also showed that, after four weeks of continuous rTMS treatment, activated regions of the brain were associated with having fewer symptoms of depression. (7)

Previous studies show that rTMS “resets” neural connections, or makes them vulnerable to reorganization, allowing them to form new communication pathways and therefore reduce the severity of depression symptoms.(3)

What Conditions Does rTMS Treat?

Research has shown rTMS to be effective at treating symptoms of a growing list of both mental and physical health conditions. In the US, rTMS is only FDA-approved to treat the following conditions:

However, numerous studies show that rTMS therapy is also safe and effective for the following conditions:

Post-traumatic stress disorder (PTSD)(11)
Tourette syndrome(12)
Chronic pain syndrome(13)
Generalized anxiety disorder (GAD)(14)
Bipolar disorder (BD)(15)
Movement disorders, such as Parkinson’s disease, functional tremors, focal epilepsy, cortical myoclonus, and spasticity(16)

How Long Does rTMS Therapy Last?

A full course of rTMS treatment consists of 36 treatment sessions administered over nine weeks. During the first six weeks of treatment, patients are asked to come into the clinic 5 days a week, for one treatment session a day. During the final three weeks of treatment, patients are “tapered off” of TMS and receive fewer sessions each week. For example, patients receive three TMS sessions in the seventh week, two sessions in the eighth week, and one final session in the ninth week.

How To Prepare for an rTMS Treatment

Patients don’t need to do anything to prepare for TMS treatment. If you like, you can bring with you anything you’d like in order to be comfortable during your session, such as reading material, headphones, etc.

What To Expect During rTMS Treatment

When you arrive for your rTMS session, you’ll be asked to sit comfortably in a chair. The rTMS technician will then place a coil over your head. Once the technician turns on the rTMS machine, you’ll hear a clicking noise and may feel a light tapping on your scalp. While this sensation may feel uncomfortable at first, it should not be painful.

Each rTMS session lasts about 20 minutes and, since rTMS does not require anesthesia, patients can return to daily life, work, etc. immediately following a session.

Your psychiatrist or rTMS technician will ask that you complete a weekly evaluation to measure your progress.

Is rTMS Safe?

Years of research and clinical trials as well as meta-analyses of clinical trials support that rTMS is safe and is a well-tolerated treatment option for adult patients.(17,18,19,20)

What Are the Possible Side Effects of rTMS?

Overall, TMS is very well tolerated and has few side effects. Side effects of TMS are generally mild and may include:

Scalp discomfort at the stimulation site
Tingling or spasms of the facial muscles
Mild headaches or brief lightheadedness

Side effects such as headache and scalp discomfort typically go away within a few hours after a treatment session and tend to decrease over time (patients generally report that after their first few TMS sessions, they no longer experience scalp discomfort or headache). If needed, these side effects can be treated with over-the-counter pain medications.

While very rare, the most severe side effect associated with rTMS is a seizure. The risk of having a seizure while undergoing TMS is similar to taking an antidepressant or anti-anxiety medication.(21) The overall risk of seizure associated with TMS is reported to be .31 per 10,000 sessions (one round of TMS treatment is 36 sessions) and .71 per 1,000 patients.(22)

Who Is a Candidate for rTMS?

In order to someone to be considered a candidate for rTMS, they must meet certain requirements. rTMS is a great treatment option for patients who:

Have been diagnosed with a condition that rTMS is clinically proven to treat (TMS is FDA-approved for the treatment of depression, depression with symptoms of anxiety, and obsessive-compulsive disorder)
Have not seen an improvement in their symptoms (or enough improvement) after trying multiple medications
Experience unpleasant side effects from medications that don’t subside or go away

While rTMS is proven to be safe, there are certain patients who do not qualify for rTMS due to safety concerns. This includes patients who:

Have a history of seizures or a seizure disorder
Have metal or electronic implants, such as an aneurysm clip or a pacemaker
Are taking a tricyclic antidepressant, an antipsychotic, or any other medication that lowers the seizure threshold(23)

Can rTMS Help You?

If you’ve been diagnosed with a condition such as depression or OCD, and you’ve tried multiple treatments without finding relief from your symptoms, rTMS might help you. Your doctor can help you understand if you’re a candidate for rTMS. Learn more about how rTMS works to relieve symptoms of depression and OCD, here.

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Resources:

1. Carpenter LL, Janicak PG, Aaronson ST, et al. Transcranial magnetic stimulation (TMS) for major depression: A multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depression and Anxiety. 2012;29(7):587-96. Link. Accessed October 24, 2022.

2. Dunner DL, Aaronson ST, Sackeim HA, et al. A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: Durability of benefit over a 1-year follow-up period. The Journal of Clinical Psychiatry. 2014;75(12):1394-401. Link. Accessed October 24, 2022.

3. Kozyrev V, Staadt R, Eysel UT, and Jancke D. TMS-induced neuronal plasticity enables targeted remodeling of visual cortical maps. 2018;115(25):6476-6481. Link. Accessed October 24, 2022.

4. Ruhr-University Bochum. What effect does transcranial magnetic stimulation have on the brain? Published June 5, 2018. Link. Accessed October 24, 2022.

5. Buchheim A, Viviani R, Kessler H, Kächele H, Cierpka M, Roth G, George C, Kernberg OF, Bruns G, Taubner S. Changes in prefrontal-limbic function in major depression after 15 months of long-term psychotherapy. PLoS One. 2012; 7(3):e33745. Link. Accessed October 24, 2022.

6. Pizzagalli, D.A., Roberts, A.C. Prefrontal cortex and depression. Neuropsychopharmacol. 2022; 47:225–246. Link. Accessed October 24, 2022.

7. Ge R, Humaira A, Gregory E, et al. Predictive Value of Acute Neuroplastic Response to rTMS in Treatment Outcome in Depression: A Concurrent TMS-fMRI Trial [published online ahead of print, 2022 May 18]. Am J Psychiatry. 2022;appiajp21050541. Link. Accessed October 27, 2022.

8. O’Reardon JP, Solvason HB, Janicak PG, et al. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biol Psychiatry. 2007;62(11):1208-1216. Link. Accessed October 11, 2022.

9. Pell GS, Harmelech T, Zibman S, Roth Y, Tendler A, Zangen A. Efficacy of Deep TMS with the H1 Coil for Anxious Depression. J Clin Med. 2022;11(4):1015. Link. Accessed October 26, 2022.

10. Trevizol AP, Shiozawa P, Cook IA, et al. Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: An Updated Systematic Review and Meta-analysis. J ECT. 2016;32(4):262-266. Link. Accessed October 11, 2022.

11. Philip NS, Barredo J, Aiken E, et al. Theta-Burst Transcranial Magnetic Stimulation for Posttraumatic Stress Disorder. Am J Psychiatry. 2019;176(11):939-948. Link. Accessed October 11, 2022.

12. Landeros-Weisenberger A, Mantovani A, Motlagh MG, et al. Randomized Sham Controlled Double-blind Trial of Repetitive Transcranial Magnetic Stimulation for Adults With Severe Tourette Syndrome. Brain Stimul. 2015;8(3):574-581. Link. Accessed October 11, 2022.

13. Hamid P, Malik BH, Hussain ML. Noninvasive Transcranial Magnetic Stimulation (TMS) in Chronic Refractory Pain: A Systematic Review. Cureus. 2019;11(10):e6019. Published 2019 Oct 29. Link. Accessed October 11, 2022.

14. Sagliano L, Atripaldi D, De Vita D, D’Olimpio F, Trojano L. Non-invasive brain stimulation in generalized anxiety disorder: A systematic review. Prog Neuropsychopharmacol Biol Psychiatry. 2019;93:31-38. Link. Accessed October 11, 2022.

15. Dell’Osso B, Mundo E, D’Urso N, et al. Augmentative repetitive navigated transcranial magnetic stimulation (rTMS) in drug-resistant bipolar depression. Bipolar Disord. 2009;11(1):76-81. Link. Accessed October 11, 2022.

16. França C, de Andrade DC, Teixeira MJ, et al. Effects of cerebellar neuromodulation in movement disorders: A systematic review. Brain Stimul. 2018;11(2):249-260. Link. Accessed October 11, 2022.

17. Machii K, Cohen D, Ramos-Estebanez C, Pascual-Leone A. Safety of rTMS to non-motor cortical areas in healthy participants and patients. Clin Neurophysiol. 2006;117:455–71. Link. Accessed August 12, 2022.

18. Loo CK, McFarquhar TF, Mitchell PB. A review of the safety of repetitive transcranial magnetic stimulation as a clinical treatment for depression. Int J Neuropsychopharmacol. 2008;11:131–47. Link. Accessed August 12, 2022.

19. Janicak PG, O’Reardon JP, Sampson SM, Husain MM, Lisanby SH, Rado JT, et al. Transcranial magnetic stimulation in the treatment of major depressive disorder: a comprehensive summary of safety experience from acute exposure, extended exposure, and during reintroduction treatment. J Clin Psychiat. 2008;69:222–32. Link. Accessed August 12, 2022.

20. Taylor R, Galvez V, Loo C. Transcranial magnetic stimulation (TMS) safety: a practical guide for psychiatrists. Australas Psychiatry. 2018;26(2):189-192. Link. Accessed August 12, 2022.

21. Stultz DJ, Osburn S, Burns T, Pawlowska-Wajswol S, Walton R. Transcranial Magnetic Stimulation (TMS) Safety with Respect to Seizures: A Literature Review. Neuropsychiatr Dis Treat. 2020;16:2989-3000. Link. Accessed October 11, 2022.

22. Taylor JJ, Newberger NG, Stern AP, et al. Seizure risk with repetitive TMS: Survey results from over a half-million treatment sessions. Brain Stimul. 2021;14(4):965-973. Link. Accessed October 11, 2022.

23. Breden Crouse EL. Transcranial magnetic stimulation for major depressive disorder: What a pharmacist should know. Mental Health Clinician. 2012;2(6):152–155. Link. Accessed August October 24, 2022.

Dr. David Woo

Dr. David Woo is the owner and head clinical psychiatrist at Madison Avenue TMS and Therapy in New York City. Dr. Woo has been seeing patients in private practice since 2002, always with the goals of combining evidence-based medicine with psychodynamic psychotherapy and collaborating with other mental health professionals to ensure the best possible outcomes for his patients. He has been certified to administer TMS at his practice since 2017. His greatest clinical interests include helping patients suffering from depression, anxiety, and obsessive compulsive disorder.

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