Repetitive Transcranial Magnetic Stimulation (rTMS) and PTSD

Repetitive transcranial magnetic stimulation (rTMS, often referred to simply as TMS) is a novel treatment for depression. Similar to the technology of magnetic resonance imaging (MRI), TMS uses magnetic pulses that are intended to specifically stimulate certain regions of the brain. A single treatment takes slightly longer than half an hour, and the average duration of treatment is 20 – 30 sessions over the course of four to six weeks.

TMS is available only by prescription and is administered under the supervision of a psychiatrist.

The magnet used in TMS causes very small electrical currents in the brain. These currents activate the neurons, which, among other responses, release neurotransmitters – which are responsible for communicating information between cells. This neurotransmitter release is similar to the way anti-depressants such as SSRIs (selective serotonin re-uptake inhibitors); SNRIs (serotonin–norepinephrine reuptake inhibitors); and DNRIs (dopamine-norepinephrine reuptake inhibitors) work. However, because medications work systemically, they can cause unwanted side effects such as nausea, dry mouth, erectile dysfunction, weight gain, restlessness and agitation. These symptoms can be responsible for patients deciding to discontinue their treatment. For example, one reported cited that up to ninety percent of patients experiencing sexual dysfunction due to antidepressant medication will stop taking the medication prematurely.

In general, approximately one-third of all patients stop taking a prescribed antidepressant within the first month, often due to unpleasant side effects.

However, the targeted pulses of the TMS coil circumvent many of the side effects associated with traditional antidepressants. In clinical trials the most common side effects associated with TMS were headaches and mild to moderate scalp pain, which tended to lessen after the first week.

Some patients also complained that the machine used in TMS therapy made loud clicking noises; wearing earplugs during TMS sessions can alleviate this. Rarely, TMS therapy patients can experience episodes of syncope (fainting) or seizure. The risk of seizure was found to be 0.003 percent per session – or 0.1 percent over the course of an average treatment length. In all, less than five percent of clinical trial participants discontinued TMS therapy because of adverse effects.

Currently, the FDA allows rTMS machines to be marketed for the treatment of major depression under certain conditions and for the treatment of migraine headaches. TMS is also used diagnostically in the evaluation of stroke, multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS, also known Lou Gehrig's disease) and movement disorders.

TMS is also being researched as a treatment for a number of other conditions, including Parkinson’s, stroke aphasia, tinnitus, chronic pain – and PTSD.

PTSD is a trauma and stressor-related disorder which may result after exposure to a traumatic or stressful event, such as combat, sexual assault, motor vehicle accident or natural disaster.

Cumulative exposure to work-related stressors, such as those experienced by police officers, firefighters, EMTs, nurses and social workers, can also result in PTSD. Symptoms of PTSD include nightmares, flashbacks, insomnia, irritable mood, distorted negative feelings about oneself and feelings of alienation and shame.

Many of the treatment options for PTSD significantly overlap with MDD treatment, including psychotherapy methods such as cognitive behavioral therapy and interpersonal therapy; and SSRI antidepressants such as Zoloft (sertraline) and Paxil (paroxetine). It therefore stands to reason that researchers would investigate TMS therapy as a possible option for PTSD patients.

Several studies have been conducted regarding the effectiveness of TMS therapy on PTSD patients, either as a standalone treatment or in conjunction with other PTSD treatments, such as imaginal exposure therapy. A meta-analysis of several TMS PTSD studies revealed its effectiveness and tolerability in the treatment of PTSD.  The analysis also indicated that right-sided treatment may be more effective than left-sided treatment. Some have speculated that this is due to the fact that increased cerebral oxygen perfusion is observed in the right prefrontal cortex when patients thought about their trauma; TMS therapy effects both oxygen perfusion and cortical excitability. Studies of this have shown: increased levels of the neurotransmitter norepinephrine, no adverse effects on concentration or memory, improvement in generalized anxiety symptoms as well as alterations in certain physical symptoms such as pain, lack of energy and appetite.

There are certain patients who should not participate in TMS therapy, specifically those with any sort of metallic implant in their head or neck, or patients with pacemakers or implantable cardioverter defibrillators (ICDs).

Additionally, many insurance companies question the effectiveness of TMS therapy for any medical condition, and therefore unilaterally do not cover the treatment. Medicare and Medicaid recognize the utility of TMS therapy but leave coverage determinations up to regional administrative contractors. Other insurance companies do cover TMS therapy, provided prior therapies, including electroconvulsive therapy (ECT), have not worked. It is important to note that most companies that choose to cover TMS therapy, only cover the therapy for MDD, not for PTSD. Therefore, unless the patient has both MDD and PTSD as comorbid conditions, insurance will generally not cover TMS therapy.


Johns Hopkins Health Alerts, "Combating Sexual Dysfunction Caused by Antidepressants," February 7, 2006, accessed July 14, 2014. 

Karsen, E. Watts, B. and Holtzheimer, P. Review of the Effectiveness of Transcranial Magnetic Stimulation for Post-traumatic Stress Disorder. Brain Stimulation 2013 Nov 25;7(2):151-157.

Miller, K. "Tempted to Quit Antidepressants?" WebMD, accessed July 14, 2014

Osuch, E. Benson, B., et al. Repetitive TMS combined with exposure therapy for PTSD: a preliminary study. Journal of Anxiety Disorders, 2009 Jan;23(1):54-9. 

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