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

Take Home Message: Three
transcranial magnetic stimulation sessions within 1 week could reduce the
intensity of mild traumatic brain injury-induced headaches.

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.

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.

by: Jane McDevitt, PhD
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