Transcranial Magnetic Stimulation
Your guide to TMS Treatment
Transcranial Magnetic Stimulation
Your guide to TMS Treatment
The Treatment
Transcranial magnetic stimulation (or TMS) is a non-invasive medical treatment that uses magnetic fields to stimulate nerve cells in the brain. TMS is delivered using a tested and approved medical device which generates a magnetic field, and directs it to a specific area of the brain. The targeting of the magnetic field is achieved using a coil, which sits in a set location next to a patient’s scalp.
TMS treatment is usually used for depression which has not responded to other types of therapy (such as medication).1 More recently, TMS has also been explored as a treatment for other conditions such as Obsessive-Compulsive Disorder (OCD), chronic pain and Parkinson’s disease.2
Because it is a non-invasive therapy, it is considered generally safe, and does not require any surgery or anaesthesia. In the vast majority of cases, patients are able to continue with normal day-to-day activities immediately after a TMS session.
Transcranial magnetic stimulation (or TMS) is commonly used to treat patients with major depression, that has not been overcome by other forms of treatment such as medication. This may mean that medication did not work, or that medication had side-effects which were deemed inappropriate for the patient. More recently, TMS researchers have focused on the treatment of conditions such as Post-Traumatic Stress Disorder (PTSD), Obsessive-Compulsive Disorder (OCD) and chronic pain.2
TMS has also been proven more effective in treating certain types of depression with greater success than others. For example, there is significantly more evidence to support TMS as a treatment for major depressive disorder (a severe form of depression), rather than the depressive episodes associated with bipolar affective disorder (where patients experience changing moods with periods of mania and depression).3 It is important to remember that while TMS has helped some, it is not a definitive ‘cure’ for all patients experiencing depression
Different types of neurostimulation treatment
Neurostimulation is a medical treatment that uses electrical or magnetic energy to stimulate the brain in order to treat certain medical conditions, and is an umbrella term, used to describe a number of different therapies.
There are several different types of neurostimulation, including Transcranial Magnetic Stimulation (TMS), repetitive Transcranial Magnetic Stimulation (rTMS), Deep Transcranial Magnetic Stimulation (dTMS)
Transcranial Magnetic Stimulation (or TMS) – is a non-invasive procedure that uses magnetic fields to stimulate specific areas of the brain. The magnetic field is generated by a coil that sits next to the patient’s head.
Repetitive TMS (or rTMS) – is a form of TMS that involves administering a series of magnetic pulses in a repetitive manner. It is the same procedure as TMS, but involves multiple magnetic pulses, delivered throughout a ‘session.’ rTMS is generally the initial therapy used to treat depression and other conditions such as OCD, PTSD and chronic pain.4[REF rTMS]
Deep Transcranial Magnetic Stimulation (or dTMS) – is an emerging treatment, and a form of TMS that involves administering magnetic pulses at a deeper level to the brain. As the name suggests, dTMS targets deeper areas of the brain. Regular TMS targets the dorsolateral prefrontal cortex, which sits fairly close to the surface of the brain. New research suggests that deeper structures may be more effective in treating some conditions.5 The dTMS coil is specially designed to target these deeper areas of the brain.
Each form of treatment is undergoing further research, and it is important that patients understand the risks and benefits.
Deep brain stimulation is a surgical procedure, where electrodes are in specific parts of the brain to treat movement disorders (such as Parkinson’s Disease).6
TMS Equipment
Transcranial Magnetic Stimulation (or TMS) – is a treatment which uses a specially designed and approved device to focus magnetic pulses onto the brain and stimulate brain activity. A magnetic coil is placed next to the patient’s head (Note: TMS is a non-invasive procedure, not cuts are made to the skin, and the coil rests up against the scalp).
Initially, careful measurements are made of the patients’ head size and the anatomical landmarks are marked on a removable cap. This cap is kept by the clinic, and in future sessions, these same locations can be used to place the magnetic coil by simply placing the cap back on the patient’s head. Essentially, the coil is placed over the region of the brain known as the dorsal prefrontal cortex – this area of the brain has been found to be involved in plays a role in working memory, goal-driven attention, task switching, planning, problem-solving, and novelty-seeking.7
The magnetic impulse itself is generated by a TMS machine – a specifically designed and approved device. It is often on a trolley next to the patient, with the coil extending out from the device. The coil can be easily moved to direct the magnetic pulses to the brain in a controlled manner.
The most common TMS coils are shaped like a figure-eight, with the two loops of the figure-eight positioned over the scalp. It does not require any incisions to the skin, and there is no anaesthetic required for TMS. The coil sits against the patient’s skin and directs a magnetic impulse to the targeted area of the brain.
Treatment information
TMS is performed in sessions. A session is generally performed no more than once a day, and each session lasts about 20 to 40 minutes.
Most patients will need to undergo a course of treatment – and often this will involve daily treatment for four to six weeks. This can vary depending on the patients’ condition, and their response to treatment.
Some patients experience improvement in symptoms within a few sessions, others will require more. Importantly, your healthcare provider will review your progress, and can adjust your treatment based on your needs.
If treatment is successful, some patients may choose to undergo ‘Maintenance TMS’ which could be a less frequent interval (like once every few months). This treatment is used to ‘top-up’ the effects of treatment and keep you performing at the improved baseline achieved by the initial course of TMS treatment.8
Transcranial magnetic stimulation (or TMS) is commonly used to treat patients with major depression1, that has not been overcome by other forms of treatment such as medication. This may mean that medication did not work, or that medication had side-effects which were deemed inappropriate for the patient.
The region of the brain targeted by TMS has wide-ranging impact on cognitive function and behaviour. As a result, researchers have expanded their focus onto many other conditions which may benefit from TMS therapy. These include: Post-Traumatic Stress Disorder (PTSD), Obsessive-Compulsive Disorder (OCD), chronic pain, cognitive impairment, neuropathic pain, and smoking cessation. These, however, do not have the same level of evidence as treatment for depression.9
Transcranial magnetic stimulation (or TMS) generally considered to be a safe treatment. However, like all medical procedures, there may be some side effects.
During the procedure these may include a discomfort or pain on your scalp, at the site of the coil.
During and after the procedure, patients may also experience headaches, lightheadedness or dizziness. These are often mild, and resolve shortly after the treatment session is finished.
It is important to notify your treating medical practitioner if you are experiencing any of these side effects. It may be possible to adjust the strength of the magnetic impulses, or the positioning of the coil next to your scalp. Finally, if the side effects are too severe, it is always possible to cease TMS treatment immediately, as there are no negative withdrawal symptoms.
Rare, but potentially serious side effects of TMS may include changes to hearing, a ringing sensation in the ears (known as tinnitus) and seizures.10 All precautions are taken to minimise the risk of these side effects, however, it is important to speak to your treating practitioner if you have any concerns.
Getting a referral and starting treatment
Treatment can usually begin as soon as a qualified medical practitioner (a psychiatrist) has assessed a patient and recommended TMS.
An assessment will involve a psychiatrist taking a history, and a physical examination.
Some factors may delay the process of receiving treatment. This can be due to wait times before seeing a psychiatrist, proximity of a patient to the nearest TMS clinic, and general availability of appointments for new patients.
Generally, yes. Medications can often be continued while receiving TMS treatment, but it is important to check with your healthcare provider first.
TMS is used once other treatment options have failed or are inadequate for the patient. This means that patients are often taking an antidepressant medication before adding TMS therapy to their treatment plan.
In Australia, it is advised to first speak to your GP about your symptoms, and if needed, get a referral to a psychiatrist.
When referred by a GP, a patient will still need to be evaluated by a psychiatrist first. The psychiatrist will then undertake a detailed history, examination and discuss treatment options, which could include TMS.
Generally, it is not advised to receive TMS while pregnant. It is considered a safe treatment, but the effects of TMS on the mother and the unborn child have not been researched conclusively, so the risk remains unknown.11
In some cases, it may be appropriate to undertake treatment if the benefits outweigh the risks. It is important to discuss your family planning with your treating doctor if you are considering TMS.
Financial impacts
The cost of transcranial magnetic stimulation (TMS) treatment in Australia can vary depending on factors such as the location of the clinic, the specific condition being treated, and whether the treatment is covered by the Medicare Benefits Schedule (MBS).
From 1 November 2021, rTMS treatment is covered by the MBS, but only for the treatment of major depressive disorder.
The schedule fee is set by Medicare as a recommended cost for each treatment. It is currently $160.00 for each treatment service and $186.40 for the prescription and mapping service.
The benefit paid by Medicare directly to the provider is 85% of the fee, making it $136 for each treatment service, and $158.45 for each prescription and mapping service. If the provider charges more than the schedule fee, the difference is paid ‘out of pocket’ by the patient, or by another organisation such as private health insurer.
Further information on rebate amounts can be found on the Australian Government, Department of Health website [External Link]
In Australia, TMS treatment is only subsidised by Medicare when treating major depressive disorder. To receive this subsidy, the patient must be eligible for Medicare and:
- Be at least 18 years of age;
- Be diagnosed with major depressive episode;
- Have failed to receive satisfactory improvement for the major depressive episode despite the adequate trialling of at least two different classes of antidepressant medications, unless contraindicated;
- Have also undertaken psychological therapy unless inappropriate; and
- Have not received rTMS treatment previously in either a public or private setting.
This is at the discretion of the treating doctor. If the treatment is eligible for the MBS rebate paid by Medicare, the treating doctor may choose to only charge this amount, known as the ‘schedule fee’. Any amount over this will be ‘out of pocket’ for the patient, and can be paid directly, or claimed through other organisations such as private health insurance.
On the day of treatment
Most likely yes. It is advised that you have alternative transport arranged for the first session, in case you experience any side effects. The most common side effects are a ‘tapping’ sensation on the scalp, a mild headache or dizziness. For most patients these side effects resolve quickly.10
If you experience any side effects, it is important to discuss these with your treating doctor, especially if feeling fatigued, as it may alter your ability to drive or operate machinery safely.
The most common side effects are a ‘tapping’ sensation on the scalp, a mild headache or dizziness. There may also be a tingling of nerves around the face. For most patients these side effects resolve quickly.10
Very rarely, patients can have severe headaches and seizures. Your treating doctor is trained to manage this. If you are concerned, or experience severe side effects, seek immediate medical attention.
Throughout the TMS procedure, patients are seated in a comfortable chair. After explaining the process, the coil will be placed over the front part of the patient’s scalp.
The treatment takes a total of about 20-40 minutes. During this time the patient will hear a ‘ticking’ noise as the magnetic impulses are directed through the coil onto the scalp.
A typical course of treatment for transcranial magnetic stimulation (TMS) typically lasts between four to six weeks. The treatment is usually given daily, and each session lasts about 20 to 40 minutes. The number of sessions required can vary depending on the individual and the condition being treated.
After treatment and your ongoing care:
Response to treatment varies between patients. Some experience benefit after the first few sessions while others may take longer. Studies have shown that, for a patient receiving daily sessions, most of the benefit will be evident to the patient within 4-6 weeks, so this became the accepted timeframe of a course of TMS treatment.
It is important to maintain realistic expectations about treatment. TMS can help relieve symptoms, but is not considered a ‘cure.’
A single session of TMS is unlikely to resolve all symptoms. This is why TMS is generally administered daily over 4-6 weeks.
Throughout this time, your treating doctor will review your progress. If there is no response to treatment, it is possible to adjust the dosage of the magnetic impulses, and refine the location of the magnetic coil.
If side effects experienced are too severe or uncomfortable to the patient, other treatment options may be considered such as medication or psychotherapy.
This depends on patient factors such as how well you responded to the initial course of therapy. After this time, your treating doctor may suggest continuing with TMS less frequently.
If treatment is successful, some patients may choose to undergo ‘Maintenance TMS’ which could be a less frequent interval (like once every few months). This treatment is used to ‘top-up’ the effects of treatment, and keep you performing at the improved baseline achieved by the initial course of TMS treatment.8
Your treating doctor may also recommend further medical or psychotherapy to assist with symptoms, alongside the TMS therapy.
References
- Lefaucheur, J. P., André-Obadia, N., Antal, A., Ayache, S. S., Baeken, C., Benninger, D. H., Cantello, R. M., Cincotta, M., de Carvalho, M., De Ridder, D., Devanne, H., Di Lazzaro, V., Filipović, S. R., Hummel, F. C., Jääskeläinen, S. K., Kimiskidis, V. K., Koch, G., Langguth, B., Nyffeler, T., Oliviero, A., … Garcia-Larrea, L. (2014). Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology, 125(11), 2150–2206. https://doi.org/10.1016/j.clinph.2014.05.021
- Rosson, S., de Filippis, R., Croatto, G., Collantoni, E., Pallottino, S., Guinart, D., Brunoni, A. R., Dell’Osso, B., Pigato, G., Hyde, J., Brandt, V., Cortese, S., Fiedorowicz, J. G., Petrides, G., Correll, C. U., & Solmi, M. (2022). Brain stimulation and other biological non-pharmacological interventions in mental disorders: An umbrella review. Neuroscience and biobehavioral reviews, 139, 104743. https://doi.org/10.1016/j.neubiorev.2022.104743
- Strelnik, A., Strelnik, S., Markina, E., Zakharov, A., Kolsanov, A., & Smirnova, D. (2022). The Effects of Transcranial Magnetic Stimulation on Cognitive Functioning in Bipolar Depression: A Systematic Review. Psychiatria Danubina, 34(Suppl 8), 179–188.
- Lefaucheur, J. P., Aleman, A., Baeken, C., Benninger, D. H., Brunelin, J., Di Lazzaro, V., Filipović, S. R., Grefkes, C., Hasan, A., Hummel, F. C., Jääskeläinen, S. K., Langguth, B., Leocani, L., Londero, A., Nardone, R., Nguyen, J. P., Nyffeler, T., Oliveira-Maia, A. J., Oliviero, A., Padberg, F., … Ziemann, U. (2020). Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014-2018). Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology, 131(2), 474–528. https://doi.org/10.1016/j.clinph.2019.11.002
- Carmi, L., Alyagon, U., Barnea-Ygael, N., Zohar, J., Dar, R., & Zangen, A. (2018). Clinical and electrophysiological outcomes of deep TMS over the medial prefrontal and anterior cingulate cortices in OCD patients. Brain stimulation, 11(1), 158–165. https://doi.org/10.1016/j.brs.2017.09.004
- Kolaya, E., & Firestein, B. L. (2021). Deep brain stimulation: Challenges at the tissue-electrode interface and current solutions. Biotechnology progress, 37(5), e3179. https://doi.org/10.1002/btpr.3179
- Jones, D. T., & Graff-Radford, J. (2021). Executive Dysfunction and the Prefrontal Cortex. Continuum (Minneapolis, Minn.), 27(6), 1586–1601. https://doi.org/10.1212/CON.0000000000001009
- Wilson, S., Croarkin, P. E., Aaronson, S. T., Carpenter, L. L., Cochran, M., Stultz, D. J., & Kozel, F. A. (2022). Systematic review of preservation TMS that includes continuation, maintenance, relapse-prevention, and rescue TMS. Journal of affective disorders, 296, 79–88. https://doi.org/10.1016/j.jad.2021.09.040
- Iriarte, I. G., & George, M. S. (2018). Transcranial Magnetic Stimulation (TMS) in the Elderly. Current psychiatry reports, 20(1), 6. https://doi.org/10.1007/s11920-018-0866-2
- Rossi, S., Antal, A., Bestmann, S., Bikson, M., Brewer, C., Brockmöller, J., Carpenter, L. L., Cincotta, M., Chen, R., Daskalakis, J. D., Di Lazzaro, V., Fox, M. D., George, M. S., Gilbert, D., Kimiskidis, V. K., Koch, G., Ilmoniemi, R. J., Lefaucheur, J. P., Leocani, L., Lisanby, S. H., … basis of this article began with a Consensus Statement from the IFCN Workshop on “Present, Future of TMS: Safety, Ethical Guidelines”, Siena, October 17-20, 2018, updating through April 2020 (2021). Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology, 132(1), 269–306. https://doi.org/10.1016/j.clinph.2020.10.003
- Pridmore, S., Turnier-Shea, Y., Rybak, M., & Pridmore, W. (2021). Transcranial Magnetic Stimulation (TMS) during pregnancy: a fetal risk factor. Australasian psychiatry : bulletin of Royal Australian and New Zealand College of Psychiatrists, 29(2), 226–229. https://doi.org/10.1177/1039856221992636
