Research Reports - rTMS in alleviating mild TBI related headaches

Pain Physician. 2016 Feb;19(2):E347-54.

Leung A(1), Fallah A(1), Shukla S(1), Lin L(1), Tsia A(1), Song D(1), Polston
G(1), Lee R(1).

BACKGROUND: Headache is one of the most common debilitating chronic pain
conditions in patients with mild traumatic brain injury. Conventional
pharmacological treatments have not been shown to be effective in alleviating
debilitating mild traumatic brain injury related headaches (MTBI-HA). Therefore,
the development of an innovative non-invasive therapy in managing MTBI-HA is
needed in the field of pain management. Repetitive transcranial magnetic
stimulation (rTMS) utilizes a basic electromagnetic coupling principle in which a
rapid discharge of electrical current is converted into dynamic magnetic flux,
allowing the induction of a localized current in the brain for neuromodulation.
The treatment is currently FDA approved for treating depression in the United
States. Recent meta-analysis studies have implicated its usage in chronic pain
OBJECTIVE: The objective of the prospective case series is to assess the
potential application of rTMS in alleviating MTBI-HA.
STUDY DESIGN: A prospective evaluation was conducted in patients with established
diagnoses of MTBI-HA and treated with neuronavigational guided rTMS.
SETTING: The study was conducted at the Veteran Administration San Diego
Healthcare System where over 400 patients with MTBI were being evaluated annually
by the Rehabilitation Medicine Service. A fraction of this patient population was
referred and evaluated in the Anesthesia Pain Clinic for the consideration of
rTMS for their headaches.
METHODS: A prospective case series was conducted with human subject protection
committee approval. Patients with established diagnoses of MTBI and constant
headaches rated at = 4 on a 0 - 10 Numerical Rating Pain Scale (NRPS), and on
stable headache medication regimens were selected to receive the treatment. Four
sessions of rTMS were delivered to specific areas of cortices over a 2-month
period. Patients' average intensities of lingering constant headaches (defined as
duration of headache lasting more than 48 hours), and the average frequency
(number of severe headache episodes per day), intensity (NRPS), and duration
(hours) of headache exacerbations were assessed before and after the rTMS
treatment protocol.
RESULTS: Six men (average age of 50) with MTBI-HA received the rTMS treatment
protocol. Average pre and post-rTMS constant headache scores (± SD) on the NRPS
were 5.50 (± 1.38) and 2.67 (± 1.75), respectively, with an average post-rTMS
headache intensity reduction of 53.05% (± 19.90). The average headache
exacerbation frequency (episodes per week) was reduced by 78.97% (±19.88) with 2
patients reporting complete cessation of severe headache episodes. For those (N =
4) with persistent headache exacerbations, the average duration and intensity of
these exacerbations were reduced by 50.0% and 31.7%, respectively.
LIMITATIONS: This prospective evaluation provides the initial insight that rTMS
may be beneficial in alleviating a debilitating chronic pain condition in
patients with MTBI-HA. More controlled randomized studies should be conducted to
validate its efficacy. Other co-existing cognitive and mood dysfunction should be
assessed as well.
CONCLUSIONS: rTMS offers a non-invasive treatment option for MTBI-HA. The tested
treatment protocol was well tolerated by the patients and can be adopted for
future randomized controlled studies in further validating the treatment

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