By Marcello Cherchi, MD PhD
For patients
Transcranial magnetic stimulation (TMS) is a treatment where a person’s head is placed in a magnetic field. This has been tried for helping people with migraines, tinnitus, and several diseases that cause balance problems.
For clinicians
Overview
Transcranial magnetic stimulation (TMS) has been studied as a treatment for several otoneurological conditions, including migraine, tinnitus, ataxia and mal de debarquement syndrome. TMS appears to be safe, but evidence for its efficacy is mixed.
Introduction
Magnetism has been used in the practice of medicine for centuries for a wide variety of ailments. In the 20th century, investigators began to apply strong magnetic fields passing through the skull — transcranial magnetic stimulation (TMS) — for several neurological disorders
Mechanism of action
Application of a magnetic field alters electrical currents, including the currents propagated by movement of ions in cells such as neurons. The mechanisms by which TMS might influence neurological activity in health and disease are incompletely understood. There is some evidence that it can modulate neural plasticity (Jannati et al. 2023), in turn probably affecting complex neural networks (Han et al. 2023).
Adverse effects
TMS appears to be safe (Brini et al. 2023).
Cautions and contraindications
TMS may be safe to use in patients with some implanted medical devices (Tendler et al. 2023), but the manufacturer of the implanted device should always be consulted first.
Relevance in otoneurology
In the 21st century investigators began exploring the application of TMS in several otoneurological conditions. The main ones are migraine, tinnitus, ataxia and mal de debarquement syndrome.
TMS has been applied to the treatment of migraine (Almaraz et al. 2010; Barker and Shields 2017; Brighina et al. 2009; Clarke et al. 2006; Leahu et al. 2018; Magis et al. 2012; McComas and Upton 2016; Ozturk et al. 2002), both in single pulse (Bhola et al. 2015; Brigo et al. 2012; Calabro et al. 2022; Dodick et al. 2010; Lan et al. 2017; Lipton et al. 2010; Lipton and Pearlman 2010; Starling et al. 2018) and repetitive (Brighina et al. 2002; Calabro et al. 2022; Dodick et al. 2010; Fumal et al. 2003; Granato et al. 2019; Lipton and Pearlman 2010; Mohamad Safiai et al. 2020) modalities. As of this writing, the only device that has received FDA approval is the Savi Dual® sTMS.
TMS has been applied to a number of cerebellar ataxias (Farzan et al. 2013; Kawamura et al. 2018; Matsugi et al. 2018; Minks et al. 2010; Nakamura et al. 2019; Rodriguez-Labrada et al. 2018; Sakuma et al. 2005; Velazquez-Perez et al. 2018; Wang et al. 2023) and multiple systems atrophy (Song et al. 2020).
TMS has been applied in the treatment of mal de debarquement syndrome (Cha et al. 2013; Cha et al. 2016; Guofa et al. 2014).
TMS (usually repetitive TMS) has been applied in the treatment of tinnitus (usually idiopathic tinnitus). Many configurations of TMS have been attempted, with variations in the stimulus pattern (De Ridder et al. 2007; Forogh et al. 2014; Khedr et al. 2008; Khedr et al. 2009; Kleinjung et al. 2008; Langguth et al. 2008b; Lo et al. 2014; Meeus et al. 2009a; Mennemeier et al. 2013; Park et al. 2015; Plewnia et al. 2007a; Vanneste et al. 2011; Weisz et al. 2014), coil position (Langguth et al. 2006b; Tringali et al. 2012), laterality of stimulation (Frank et al. 2010; Khedr et al. 2010; Kim et al. 2014a; Kim et al. 2014b; Mennemeier et al. 2013; Schecklmann et al. 2015), single- versus multi-site stimulation (Burger et al. 2011; Kreuzer et al. 2011; Kreuzer et al. 2015; Lehner et al. 2016; Lehner et al. 2013a; Lehner et al. 2012; Lehner et al. 2013b; Noh et al. 2017; Park et al. 2013; Schecklmann et al. 2015), and in conjunction with other treatment modalities (Bilici et al. 2015; De Ridder et al. 2011; Fregni et al. 2006; Kleinjung et al. 2011; Kleinjung et al. 2009; Kreuzer et al. 2016; Langguth et al. 2008a; Vielsmeier et al. 2018; Zhang and Ma 2015). Many studies conclude that TMS is efficacious in the treatment of tinnitus; some of these studies are placebo-controlled (Anders et al. 2010; Cacace et al. 2017; De Ridder et al. 2013; Eichhammer et al. 2003; Folmer et al. 2006; Folmer et al. 2015; Kleinjung et al. 2005; Kleinjung et al. 2006; Langguth et al. 2007; Lee et al. 2013; Lehner et al. 2013a; Marcondes et al. 2010; Meeus et al. 2009a; Mennemeier et al. 2011; Piccirillo 2016; Rossi et al. 2007; Smith et al. 2007; Theodoroff et al. 2017; Vanneste et al. 2011; Wang et al. 2015; Wang et al. 2016b; Yilmaz et al. 2014), while others are not placebo-controlled (Burger et al. 2011; Chung et al. 2012; De Ridder et al. 2012; De Ridder et al. 2005; Frank et al. 2010; Khedr et al. 2010; Khedr et al. 2008; Kim et al. 2014a; Kim et al. 2014b; Kleinjung et al. 2011; Kleinjung et al. 2009; Kleinjung et al. 2007; Kreuzer et al. 2011; Kreuzer et al. 2015; Kreuzer et al. 2016; Kreuzer et al. 2017; Labar et al. 2016; Langguth et al. 2004; Langguth et al. 2008b; Lehner et al. 2016; Lehner et al. 2013a; Lehner et al. 2012; Lehner et al. 2015; Lehner et al. 2013b; Lo et al. 2014; Mennemeier et al. 2008; Mennemeier et al. 2013; Minami et al. 2011; Noh et al. 2017; Park et al. 2015; Park et al. 2013; Plewnia et al. 2003; Plewnia et al. 2007a; Plewnia et al. 2007b; Poreisz et al. 2009; Schecklmann et al. 2014; Schecklmann et al. 2015; Ting et al. 2011; Vanneste et al. 2010; Wang et al. 2016a; Yang et al. 2013). Other studies conclude that TMS is ineffective in the treatment of tinnitus; some of these studies are placebo-controlled (Engelhardt et al. 2014; Hoekstra et al. 2013; Landgrebe et al. 2017; Langguth et al. 2014; Piccirillo et al. 2011; Piccirillo et al. 2013; Plewnia et al. 2012; Roland et al. 2016; Sahlsten et al. 2017), while others are not placebo-controlled (Weisz et al. 2014). Systematic review and meta analyses of this literature arrive at different results (Londero et al. 2018); some analyses conclude that TMS “may be effective” (Langguth et al. 2006a; Peng et al. 2012), others conclude that there is insufficient evidence to support TMS as a treatment for tinnitus (Meng et al. 2011), and others conclude that more research is needed to answer this question (Londero et al. 2006; Meeus et al. 2009b; Soleimani et al. 2016; Theodoroff and Folmer 2013).
Other notes
TMS appears to be safe, but we still regard it as an experimental treatment modality.
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