TMS Pain Relief Approaches and Related Mechanisms

Release time :2024-10-29

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The International Association for the Study of Pain has designated the third Monday of October each year as "World Pain Day." Neuropathic pain (NP) refers to pain caused by damage or disease affecting the somatosensory system. It is characterized by injury to the central or peripheral nervous system and is one of the most difficult types of pain to treat in clinical settings, with an annual incidence rate of 0.82%.

Functional magnetic resonance imaging (fMRI) has enabled researchers to discover the potential pain-relieving effects of TMS. TMS can alleviate pain through multiple mechanisms, including altering cortical excitability, improving cerebral blood flow, activating or inhibiting pain perception areas, changing neural plasticity, influencing the hypothalamic-pituitary-adrenal (HPA) axis, and regulating neurotransmitters and inflammatory factors.

In areas such as chronic pain and neuropathic pain, TMS technology has already demonstrated significant therapeutic effects. In the 2019 "Evidence-Based Guidelines for TMS Therapy" published by the International Federation of Clinical Neurophysiology (IFCN), high-frequency rTMS stimulation of the contralateral M1 region is rated as an A-level recommendation for treating neuropathic pain. This shows that TMS can be confidently used in clinical practice to improve patients' pain symptoms.

We have reviewed the literature to gather treatment protocols for various pain-related indications using TMS and have provided a summary of the underlying mechanisms.

Migraine

  • Protocol:
TargetIntensityFrequencyNumber of TrainsITINumber of Sessions
Occipital Cortex100%RMTiTBS(50Hz/5Hz)2010s5 sessions per week for two weeks
  • Possible Mechanisms: TBS may affect the formation and spread of cortical spreading depression (CSD), which is part of the neurological theory of migraines, thereby reducing migraine attacks. It may also influence the process of activating the trigeminal nerve endings around cerebral blood vessels, as proposed in the trigeminovascular reflex theory of migraines, affecting the pain transmission pathways in patients.

Postherpetic Neuralgia

  • Protocol
TargetIntensityFrequencyTrain DurationITITotal Pulses
Healthy Side M180%RMT10Hz0.5S3s1500
  • Possible Mechanism: Stimulating the M1 region may excite the thalamus through the cortico-thalamic circuit, thereby inhibiting the transmission of pain signals through the spinothalamic pathway.

Neuropathic Pain Following Spinal Cord Injury

  • Protocol
TargetIntensityFrequencyTrain DurationITITotal Pulses
M1 on the Painful side of the body110%RMT10Hz5s25s1500
  • Possible Mechanism: The analgesic effect of TMS stimulation on the motor cortex depends on altering the activity of the motor cortex and inducing plasticity changes, as well as its projections to brain areas involved in pain processing, such as the thalamic nuclei, anterior cingulate cortex, and periaqueductal gray in the brainstem.

Chronic Pain After Ischemic Stroke

  • Protocol
TargetFrequencyTotal PulsesDuration
Bilateral M11Hz100015min per side, 1 session per day
  • Possible Mechanism: After localized current generation, stimulation induces the release of endogenous opioid peptides in the central nervous system while repairing damaged neuronal cells, thereby achieving a therapeutic effect on post-stroke pain.

Fibromyalgia

  • Protocol
TargetIntensityFrequencyTrain DurationITITotal Pulses
L-DLPFC120%RMT10Hz4s21s3000
  • Possible Mechanism: The DLPFC is a key area that regulates pain perception by directly modulating subcortical and cortical pathways. Additionally, the DLPFC is involved in multiple cognitive, emotional, and sensory networks, which can improve various symptoms of fibromyalgia, including mood and fatigue.

Primary Trigeminal Neuralgia

  • Protocol
TargetIntensityFrequencyTrain DurationITITotal Pulses
Healthy Side M180%RMT10Hz0.5s3s1500
  • Possible Mechanism: rTMS acts on the cortical areas of the brain, influencing the trigeminal nerve by regulating neural conduction and neurotransmitter secretion, thereby improving facial movement.

Glossopharyngeal Neuralgia

  • Stimulation Protocol: Use the iTBS mode, targeting the glossopharyngeal nerve.  
  • Possible Mechanism: Peripheral magnetic stimulation generates analgesic effects by interfering with peripheral impulse conduction, activating large afferent nerve fibers, regulating peripheral nerves and dorsal root ganglia, affecting endogenous opioid pathways, and activating spinal and supraspinal inhibitory mechanisms.

Complex Regional Pain Syndrome (CRPS)

  • Stimulation Protocol: Use the iTBS mode, targeting the superficial flexor muscles of the fingers.
  • Possible Mechanism: Peripheral magnetic stimulation can increase proprioceptive signals flowing to the brain from the bottom up, thereby influencing neural plasticity as well as pain and motor control mechanisms.

Carpal Tunnel Syndrome

  • Protocol
TargetFrequencyTrain DurationITITotal Pulses
median nerve10Hz1s5s1000
  • Possible Mechanism: Stimulating the median nerve may project through pathways to the sensorimotor cortex, modulating cortico-spinal motor commands and increasing proprioceptive input, thereby enhancing cortical excitability and improving motor performance.

Lumbar Radiculopathy

  • Protocol
TargetFrequencyTrain DurationITITotal Pulses
Lumbar10Hz0.5s5s1000
  • Possible Mechanism: Peripheral repetitive magnetic stimulation significantly alleviates pain caused by lumbar radiculopathy, with notable improvements in electromyographic (EMG) indicators. The possible mechanisms include terminal nerve reinnervation or nerve sprouting.

Statement 

1. This content is organized by the Clinical Support Department of Shenzhen Yingchi Technology Co.,Ltd. Criticisms and corrections are welcome. For reprint, please indicate the source.

2. Reference:

[1] Dana E, Tran C, Osokin E, Westwood D, Moayedi M, Sabhaya P, Khan JS. Peripheral magnetic stimulation for chronic peripheral neuropathic pain: A systematic review and meta-analysis. Pain Pract. 2024 Apr;24(4):647-658. doi: 10.1111/papr.13332. Epub 2023 Dec 16. PMID: 38102884.

[2] Zhou J, Wang Y, Luo X, Fitzgerald PB, Cash RFH, Fitzgibbon BM, Che X. Revisiting the effects of rTMS over the dorsolateral prefrontal cortex on pain: An updated systematic review and meta-analysis. Brain Stimul. 2024 Jul-Aug;17(4):928-937. doi: 10.1016/j.brs.2024.07.011. Epub 2024 Jul 30. PMID: 39089648.

[3] Cioni B, Meglio M. Motor cortex stimulation for chronic non-malignant pain: current state and future prospects[J]. Acta Neurochir Suppl, 2007, 97(Pt 2):45-49

[4] Pridmore S, Oberoi G, Marcolin M, et al . Transcranial magnetic stimulation and chronic pain: current status[J]. Australas Psychiatry, 2005, 13(3):258-265.

[5] Yohei T, Shingo O, Takashi O, et al . Effects of 1-Hz repetitive transcranial magnetic stimulation on acute pain induced by capsaicin[J]. Pain, 2004, 107(1-2):107-115.

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