Transcranial Magnetic Stimulation (TMS)

Description and principles of action

In 2008, Transcranial Magnetic Stimulation received Food and Drug Administration approval in the US for the treatment of Treatment-Resistant Depression, and in 2018 for the treatment of Obsessive-Compulsive Disorder (OCD). Large clinical trials are being conducted within different disciplines and in different conditions; therefore, there is increasing clinical evidence regarding the effectiveness of Neuromodulation Therapies, even off-label.

Transcranial magnetic stimulation (TMS) is based on the principle of electromagnetic induction, which allows the physician to stimulate or inhibit the neuronal activity of specific brain areas. An electrical impulse generates a magnetic field that penetrates through the skull and induces the stimulus in the nervous tissue that modulates the activity of neurons. The effect can be of two types:

• Activation (induction/increase of the electrical activity of an otherwise inactive or hypoactive area);

• Inhibition (reduction of electrical activity in progress in the given area).

Laboratory studies performed in rats suggest that the action occurs through the improvement of the signaling activity of the neurotrophic factor, BDNF-tropomyosin receptor kinase B (TrkB), which is a biomarker of neural plasticity. ― BDNF: Brain Derived Neurotrofic Factor.

Types of TMS

There are different types of TMS, which can be applied in a customized manner to achieve the specific therapeutic goal set for the single patient:

• rTMS: uses repetitive pulse stimulation.

• Theta Burst Stimulation (TBS): this is a type of stimulation characterized by the rapid repetition of high-frequency stimuli (50 Hz) divided into triplets of stimuli. Two types of protocols are distinguished within TBS: those that reduce cortical activity (continuous TBS) and those that increase it (intermittent TBS).

• Deep Transcranial Magnetic Stimulation (Deep TMS): an innovative method in the field of Neuroscience that, unlike those previously described, acts by stimulating brain regions at the subcortical level, again noninvasively. In-depth article: Personalized brain stimulation lifts a patient’s depression.

• Theta-Burst Multi Session Treatment (SNT): is a new high-frequency, high-intensity, multi-session daily TMS protocol and is considered a breakthrough in the treatment of severe Drug-Resistant Depression.

Dr. Pallanti published a study conducted on 24 patients with Severe Depression resistant to any treatment who responded, in over 80% of cases, to this protocol. The Pallanti Method, in addition to being surprisingly effective proved to be extremely well tolerated. The result is so positive that the FDA, the federal agency for approving new treatments, is considering making an exception so that it will be accessible and even reimbursable in the US.

Everyone can benefit from Neuromodulation Therapy performed with TMS, except in the following cases:

• Presence of previous seizures - Epilepsy;

• Presence of Pacemakers;

• Cochlear implants.

How does rTMS work?

Before starting TMS treatment, we use Neuronavigation to precisely identify the brain area to be stimulated with excitatory or inhibitory pulses.

In rTMS therapy, an instrument called a stimulator supplies electrical energy to a magnetic coil that generates a magnetic field in the brain for a short period of time.

The magnetic field produced by the coil passes unobstructed through the scalp to the encephalon without any scattering and in an almost painless manner thus being able to reach the underlying brain structures, particularly the cerebral cortex, and change its electrical activity in a way that improves the symptoms of psychiatric disorders.

The coil is placed on the head in such a way as to allow the magnetic field to reach the region of the brain of interest. The magnetic stimulus produces a recordable response, which manifests as a noise similar to a series of clicks and a tingling-like sensation on the skin of the head.

The most commonly reported side effect of rTMS is a mild, transient muscle-tensive headache.

Learn more about this topic by watching the video below (activate English subtitles by clicking on the gear symbol)! ↓

Therapeutic areas

Neuromodulation Therapies offered by the Istituto di Neuroscienze can be applied effectively ― as off-label but scientifically validated therapies ― in a broad spectrum of neuropsychiatric areas and on different types of patients:

In Psychiatry:

― Drug-Resistant patients;

― Patients with residual symptoms;

― Patients with cognitive symptoms;

― ECT candidates or ECT resistant patients;

― Patients with Mood Disorders (Depression, Bipolar Disorder);

― Reproductive Psychiatry patients (pregnant women);

― Post-partum Depression;

― Patients undergoing assisted fertilization;

― Depression associated with metabolic disorders;

― Depression for cases where medications should be avoided (liver / kidney failure);

― Seasonal Depression;

― Autism - reduction of repetitive behaviors and improvement of communication;

― Psychosis - reduction of hallucinations, reduction of negative symptoms;

― Obsessive Compulsive Disorder and OCD Spectrum Disorders (Trichotillomania, Tics);

― Behavioral addictions (Gambling, Internet, Pornography);

― Substance Use Disorders (Cocaine, Alcohol, THC);

― Diabetes.

In Neurology:

― Cognitive rehabilitation;

― Post-stroke rehabilitation or head trauma;

― Pain, including headaches and fibromyalgia;

― Parkinson's Disease;

― Tinnitus (Tinnitus).

― Insomnia.

In Weight and Nutrition Disorders:

― Carbohydrate Craving;

― Obesity and Binge Eating;

― Eating Disorders.

How do Neuromodulation therapies work in practice?

The duration of individual treatment can vary depending on the specific therapy and can range from a few minutes to just under an hour.

It is necessary to remain awake during stimulation and it is possible to read and talk.

The practitioner/physician will ask a few simple questions about daily progress regarding:

• Activities performed during the day, rest, nutrition;

• Subjective mood and progress of symptoms;

• Pharmacotherapy, in order to monitor any changes or modifications;

• Alcohol and/or substance intake: substances such as alcohol, marijuana and cocaine can interfere with therapy and produce a change in pacing parameters.

Listen to one of our patient's testimony on the effectiveness of TMS in addiction treatment (activate English subtitles by clicking on the gear symbol)! ↓

Treatment procedures

TMS sessions are given daily for one or more sessions per day, unless specifically indicated. The minimum duration of therapy should be longer than 20 sessions, but as a rule the more sessions the better. In the US, the first course of treatment lasts no less than 40-50 sessions.

Sessions are conducted on an outpatient basis under constant supervision. In fact, the goal is to stimulate the patient to adopt an active attitude so that he or she makes available to himself or herself every useful resource for change, the cornerstone of any therapy.

The beneficial effects may not be immediate: this depends from person to person.

At the end of the initial cycle, the usefulness of extending treatment further is evaluated. If the beneficial effects become evident toward the end of the agreed cycle, surely it is advisable to prolong the treatment period to consolidate the effect.

Reevaluation and recall visits should be established, which is crucial to consolidate the effects obtained during the first cycle and reduce the risk of future relapse.

Follow-up and recall visits

The mere disappearance/decrease of the symptom does not coincide with the disappearance of the disease.

Even after the symptom disappears or diminishes, the brain circuit disorder may remain. If one stops therapies, pharmacological or Neuromodulation, the symptom reappears perhaps in a different form from the first one (relapse). At that point it will be more difficult and take longer to return to feeling better.

In order to avoid relapse, it is important to schedule regular booster treatment sessions, which are generally done shortly after the end of the first cycle and consist of a few consecutive days of treatment.

The duration of the reevaluation visits cannot be established a priori but depends on the patient's symptomatology, the effects achieved in the first course of treatment, and any comorbidities that may make the clinical picture more complex, consequently increasing the incidence rate of relapse.

The protocol as well as the type of Neuromodulation therapy (as well as other current therapies) may undergo modifications in order to best adapt to changes in each individual's clinical and metabolic condition. That is why the treatments are valid for 2 months, after which, they must be reevaluated: one cannot go on with the same treatments beyond two months, unless otherwise directed by the doctor.

We kindly ask you to:

Arrive at the Istituto di Neuroscienze at least 15 minutes before your appointment so that paperwork can be completed.

Show up on time at the agreed-upon time for the start of treatment so that you can take advantage of the full program scheduled for the day.

Consider that no recoveries or refunds are made for treatments not taken for causes outside the responsibility of the Istituto di Neuroscienze.