Repetitive transcranial magnetic stimulation in managing mild traumatic brain injury-related headaches
Leung A., Shukla S., Fallah A., Song D., Lin L., Golshan S., Tsai A., Jak A., Poston G., Lee. Neuromodulation 2015; ahead of print.
Take Home Message: Three transcranial magnetic stimulation sessions within 1 week could reduce the intensity of mild traumatic brain injury-induced headaches.
Persistent and debilitating headaches are common after a mild traumatic brain injury (mTBI). These headaches are associated with depression as well as attention and memory deficits. Many patients with these headaches opt to self-medicate; however, these medications provide little relief and have many side effects. Transcranial magnetic stimulation (TMS) is an approved treatment for alleviating medication-resistant depression symptoms and migraines. However, the efficacy of TMS on the motor cortex for mTBI-induced headache is untested. Therefore, the authors conducted a single-blinded randomized controlled trial to assess the effect of repetitive TMS to the motor cortex in alleviating mTBI-induced headache. Twenty-four patients (~41 years of age) that suffered head trauma resulting in a persistent headache for over 3 months (with no headache problems prior to mTBI) were randomly allocated into 2 groups (treatment and sham treatment). The participants within the treatment group received 20-second TMS stimulation at 100 pulses delivered at 10 Hz over the motor cortex, 3 times within 1 week. Prior to the TMS applications, all the participants completed the Conner’s Continuous Performance Test II (identified baseline attention function), Hamilton Rating Scale for Depression, Mississippi scale for Posttraumatic Stress Disorder, and Brief Pain Inventory. Additionally, all the patients provided a daily (three session) headache diary. In the diary they reported if they had a persistent headache (chronic headache that never goes away) or debilitating headache (intense headache that debilitates a person from activities of daily life) in the past 24 hours as well as the intensity (0-10 numeric rating scale) and duration of the headache. The authors collected post-treatment measurements at 1 and 4 weeks following the 3 TMS applications. There were no differences between groups at baseline. The TMS treatment group reported a larger reduction in percentage of persistent headache and headache intensity 1-week post final treatment compared to the sham group. The TMS treatment group also reported a larger reduction in debilitating headache exacerbation 4-weeks post final treatment compared with the sham group There were no differences between groups for changes in attention function, depression, posttraumatic stress disorder symptoms, or pain.
This is an important study because it is one of the few randomized controlled trials trying to test treatment strategies for concussions. The authors found that TMS to the motor cortex significantly reduced the intensity of consistent daily headaches one week, and debilitating headaches 4 weeks after the 3 treatment sessions. Though there were no difference in baseline assessment scores the drop in persistent and debilitating headache scores were fairly large, especially with the debilitating headaches. It is encouraging to see a 50% reduction in headache intensity after just 3 brief treatments and that the reduction of debilitating headaches was seen a month after these TMS treatments. It was also interesting to note that the TMS treatment had minimal side effects. Only 1 patient in the treatment group reported dizziness, which resolved within 10 minutes. Due to the frequency and the long-term adverse effects of mTBI-induced chronic headaches different types of treatment would be beneficial to both medical professionals and patients. Many patients opt to just pop a pill; however, due to the low amount of relief and high risk of adverse effects it would make sense for clinicians to talk to patients about TMS, which could be a quick and low-risk treatment.
Questions for Discussion: Would you refer your patient suffering from chronic headaches induced from mTBI for a transcranial magnetic stimulation? Do you believe that long-term transcranial magnetic stimulation (once a month) could eventually lead reduction in depression signs and symptoms? Could transcranial magnetic stimulation alter structural consequences of mTBI.
Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban
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Leung A, Shukla S, Fallah A, Song D, Lin L, Golshan S, Tsai A, Jak A, Polston G, & Lee R (2015). Repetitive Transcranial Magnetic Stimulation in Managing Mild Traumatic Brain Injury-Related Headaches. Neuromodulation : Journal of the International Neuromodulation Society PMID: 26555886