A patient-oriented analysis of pain side effect: A step to improve the patient's experience during rTMS?

Abstract

Background: Repetitive transcranial magnetic stimulation (rTMS) is an efficacious and well-tolerated intervention for treatment-resistant depression (TRD). A novel rTMS protocol, intermittent theta burst stimulation (iTBS) has been recently implemented in clinical practice, and it is essential to characterize the factors associated to pain and the trajectory of pain of iTBS compared to standard rTMS protocols. Objective: We aimed to characterize the side effect profile and the pain trajectories of High-Frequency Left (HFL) and iTBS in TRD patients in the THREE-D trial. We also investigated factors associated to pain and the relationship between pain and clinical outcomes. Methods: 414 patients were randomized to either HFL or iTBS. Severity of pain was measured after every treatment. General Estimating Equation was used to investigate factors associated with pain. Latent class linear mixed model was used to investigate latent classes of pain trajectories over the course of rTMS. Results: Higher level of pain was associated with older age, higher stimulation intensity, higher anxiety, female, and non-response. The severity of pain significantly declined over the course of treatments with a steeper decrease early on in the course of the treatment in both protocols, and four latent pain trajectories were identified. The less favorable pain trajectories were associated with non-response and higher stimulation intensity. Conclusions: HFL and iTBS were associated with similar factors and pain trajectories, although iTBS was more uncomfortable. Response to rTMS was associated with less pain and more favorable pain trajectories furthering the evince base of overlapping neurobiological underpinnings of mood and pain. We translated these results into patient-oriented information to aid in the decision-making process when considering rTMS.

Competencies for Repetitive Transcranial Magnetic Stimulation in Postgraduate Medical Education: Expert Consensus Using a Modified Delphi Process

“…The number of items that could be assessed are quite broad including scalp tenderness, pain, seizures, as well as competency in educating the patient and caregivers. 24,25 This is similar for statement 14, "Manage immediate complications (e.g., Seizure) arising from rTMS" where complications may include seizures and tachycardia. 25,26 It is expected that even though these may be rare complications arising from rTMS, learners should be able to manage and triage this as these complications can be life-threatening.…”

Differential symptom cluster responses to repetitive transcranial magnetic stimulation treatment in depression

“…Comparative studies of pharmacotherapy with rTMS using consistent analytic techniques will be required to determine whether our findings are unique to rTMS or are consistent across depression treatment modalities. If there are unique effects observed by treatment modality, it will then be important to consider mechanisms of observed differences and whether side effects such as pain, which is associated with anxiety in rTMS, 31 mediate symptom cluster response. Similarly, it will also be important to determine whether differing rTMS treatment targets (i.e., right DLPFC or DMPFC), can achieve greater relative reductions in anxiety symptoms, as suggested by prior hypothesis generating work.…”