Frequently Asked Questions About Transcranial Magnetic Stimulation

Why does TMS work? 

TMS has been shown to produce changes in neuronal activity in regions of the brain implicated in mood regulation, such as the prefrontal cortex. As each magnetic pulse passes through the skull and into the brain, this induces brief activity of brain cells underlying the treatment coil. The frequency of pulse delivery also influences whether brain activity is increased or decreased by a session of TMS. Recent studies also suggest that stimulation over the left and right sides of the brain can have opposite effects on mood regulation (depression vs anxiety/OCD).

When is TMS used? 

Antidepressant medications and psychotherapy are the first line treatments for major depression. These treatments, however, do not work for all patients. In these instances, TMS might be used as an alternative treatment, or to augment antidepressant medications, ketamine/Spravato, or psychotherapy. Patients who have failed to achieve an adequate response from at least 2 to 3 antidepressants, or who are unable to tolerate medications, might consider TMS therapy.

What happens during an TMS procedure? 

Because TMS uses magnetic pulses, before beginning a treatment, patients are asked to remove any magnetic-sensitive objects (such as jewelry). TMS produces a loud clicking sound with each pulse, much like an MRI machine. Patients are seated during each session of TMS. During the first rTMS session, several measurements are made to ensure that the TMS coil will be properly positioned over the patient’s head. Once this is done, the TMS coil is suspended over the patient’s scalp. We then measure the patient’s motor threshold, by administering several brief pulses. The motor threshold is the minimum amount of power necessary to make the patient’s thumb twitch, and varies from individual to individual. Measuring the motor threshold helps the physician personalize the treatment settings and determine the amount of energy required to stimulate brain cells. Once the motor threshold is determined, the coil is then brought forward so that it rests above the front region of the patient’s brain. Treatment is then commenced. During the treatment, patients will hear a series of clicking sounds and will feel a tapping sensation under the treatment coil. Motor threshold is not checked at every treatment but may be reassessed if there is concern it may have changed, for example, because of a change in medication.

Who administers TMS? 

TMS is always prescribed by our psychiatrist here at Ascend Health Center. The treatment itself is administered by an experienced TMS technician under the supervision of the TMS physician, or by the nurse anesthetist. 

The TMS technician or physician will always be present to monitor the patient during the treatment. The patient can stop a treatment at any time by asking the staff member present. 

How long is an TMS procedure? 

TMS therapy involves a series of treatment sessions. Treatment sessions vary in length depending on the TMS coil used and the number of pulses delivered but typically last around 1-3 minutes. Patients receive TMS up to 5 days a week. A typical course of TMS is 4 to 6 weeks. However, this can vary depending on an individual’s response to treatment.

Do I need to be hospitalized for a course of TMS? 

Unlike ECT, TMS does not require any sedation or general anesthesia, so patients are fully awake and aware during the treatment. There is no “recovery time”, so patients can drive home afterwards and return to their usual activities.

What are the side-effects of TMS? 

TMS is well-tolerated and associated with few side-effects and only a small percentage of patients discontinue treatment because of these. The most common side-effect, which is reported in about half of patients treated with TMS, is headaches. These are mild and generally diminish over the course of the treatment. Over-the-counter pain medication can be used to treat these headaches.

About one third of patients may experience painful scalp sensations or facial twitching with TMS pulses. These too tend to diminish over the course of treatment although adjustments can be made immediately in coil positioning and stimulation settings to reduce discomfort. 

Some patients may still complain of hearing problems immediately following treatment. No evidence suggests these effects are permanent, and earplugs can be worn during the treatment.

TMS has not been associated with many of the side-effects caused by antidepressant medications, such as gastrointestinal upset, dry mouth, sexual dysfunction, weight gain, or sedation.

The most serious risk of TMS is seizures. However, the risk of a seizure is exceedingly low. At Ascend, we follow up-to-date safety guidelines that are designed to minimize the risk of seizures. While TMS is a safe procedure, it is important to point out that because it is a new treatment (first developed in the 1980’s), there may be unforeseeable risks that are not currently recognized. 

Who cannot get TMS therapy? 

Patients with any type of non-removable metal in their heads (with the exception of braces or dental fillings), should not receive rTMS. Failure to follow this rule could cause the object to heat up, move, or malfunction, and result in serious injury or death. The following is a list of metal implants that can prevent a patient from receiving rTMS: 

  • Aneurysm clips or coils 
  • Stents in the neck or brain 
  • Deep brain stimulators 
  • Electrodes to monitor brain activity 
  • Metallic implants in your ears and eyes 
  • Shrapnel or bullet fragments in or near the head 
  • Facial tattoos with metallic or magnetic-sensitive ink 
  • Other metal devices or object implanted in or near the head 

Also, TMS is self-pay for anxiety, insomnia, and OCD. Insurance only covers TMS for depression if multiple medications have failed.

Who will benefit the most? 

Existing evidence to date suggests that patients who are less treatment-resistant respond better to TMS than those who are highly treatment-resistant. However, there is much yet to be learned about particular variables that may impact response to TMS. Researchers are presently conducting clinical studies to evaluate who will benefit most from TMS therapy. For example, there is a lot of interest in evaluating whether TMS with antidepressant medications or Spravato/ketamine is more effective than TMS alone.

How can I get TMS treatment? 

TMS is one of the brain stimulation treatments for depression offered at Ascend Health Center. Before scheduling you for treatment, you must first be evaluated by our psychiatry team to determine if TMS would be safe and appropriate for you.

How likely is TMS to cure my depression? 

At Ascend, some patients are able to stop taking all of their meds and still don’t require additional treatment years later. About a fourth of patients don’t get better. The majority have depression that lifts by 50%, as documented on depression scales, and can reduce the number of anti-depressants they take. Insurance will reapprove TMS if the effects fade after six months, but we’ve never needed to do two series that close together.  

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