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Transcranial Magnetic Stimulation and Multiple Sclerosis Fatigue: An Off-Label, Novel Use of Deep TMS

Transcranial Magnetic Stimulation and Multiple Sclerosis Fatigue: An Off-Label, Novel Use of Deep TMS

Summary

MS fatigue, affecting up to 90% of patients, presents a significant challenge. Deep Transcranial Magnetic Stimulation (dTMS), originally used for mental health conditions, shows promise as an off-label treatment for MS fatigue. Administered over six weeks, dTMS has demonstrated efficacy in reducing fatigue scores by over 26% in small-scale studies. Despite mild side effects, such as headache and neck pain, reported benefits include a 50% reduction in fatigue symptoms. dTMS offers a non-invasive alternative to daily medication regimens and represents a hopeful avenue for improving the quality of life for MS patients.

The information in this blog is not FDA-approved. Research articles are cited. Hopemark Health staff focus on psychiatry specifically, not neurology. Talk to your neurologist about any treatment of your neurological condition. 

Edited by Laura Nash, VP of Growth and TMS

Tired Girl

Multiple Sclerosis (MS) is an unpredictable and potentially disabling autoimmune disease of the central nervous system. It can disrupt the flow of information within the brain, and between the brain and the body. While not all people experience the same MS symptoms, one of the most common symptoms is fatigue. Fatigue affects a staggering number of people with MS, between 80-90% of those living with MS experience this symptom. The reason fatigue is so prominent is not well understood and may be multifactorial. The symptoms of MS can lead to disability and poor quality of life Fatigue is a major contributor to this debilitating illness. Other symptoms may include troubles with gait and dexterity, cognitive changes, spasticity, bowel and bladder problems, mood changes including depression, sexual problems, and vision problems. Everyone’s experience with MS is different, and these losses may be temporary, or they may be long lasting. While a cure for MS is not yet discovered, there are FDA approved medications to treat MS, to slow down progression, and to manage some of the symptoms.  

There are effective new treatments on the horizon. One such treatment is deep transcranial magnetic stimulation, or dTMS DTMS is a non-medication, non-invasive treatment being studied with promising results for fatigue in MS. The dTMS was developed by Brainsway, and uses H Coil technology to create an electromagnetic field inside a helmet that is fitted over the patient’s head. It delivers pulses that can stimulate neuronal activity in the brain. Currently, dTMS is FDA-approved to treat major depression, anxious depression, OCD, and nicotine dependence. Additionally, it is being researched for various off label indications like MS fatigue. The treatment for MS fatigue is delivered in an office setting while the patient is awake, alert, and seated comfortably in a chair.  For MS, dTMS has shown benefit when administered three times per week over the motor threshold for 6 weeks. Each of the dTMS sessions lasts 20 minutes. Deep TMS does stimulate more of the brain regions than the traditional rTMS (figure 8 shaped coil) but both types of TMS have been studied for fatigue and other various symptoms of MS. It is thought that TMS achieves its beneficial effects through causing changes to the brain by stimulating NMDA and AMPA receptors, which are both responsible for neuroplasticity, and rewire the brain in a positive way. This effect creates secretion of a hormone called BDNF, which reduces brain cell (neuron) breakdown and stimulates growth of parts of the neuron (dendrites), forming new connections in the brain. This causes changes in the brain and the lasting benefits of TMS treatment.

Studies done on TMS for MS fatigue have been small, including 20-40 patients each. They are double blinded, and placebo controlled using a sham treatment in place of the true TMS treatment, so it is impossible to tell the difference while administering the treatments. Using the MS fatigue protocol, benefits can be observed around week 2-3 for patients who get the actual TMS treatment versus the sham control. Studies show significant reduction in fatigue scores (scores dropped by over 26% in most studies). Because these studies have been small, more, larger studies are required for TMS to be FDA approved for MS fatigue.  

In 2023 at Hopemark Health, a patient diagnosed with MS underwent the dTMS protocol for MS fatigue. The TMS was well tolerated. The patient stated her chronic headaches improved dramatically during the treatment. She did not get headaches during the procedure. Her fatigue scores dropped by an impressive 50% from treatment 1 to treatment 18. The patient remarked enthusiastically after her treatment ended “I didn’t even realize how bad my fatigue was and how much it affected my day-today life until week 3 when I saw how much easier it was to do day to day tasks. I was better able to problem solve, enjoy things fully without being so fatigued, and I wasn’t counting the hours till I could lay down at the end of the day.” This patient was diagnosed with MS in 2007 and is under the care of a neurologist who was aware of and in support of the off-label TMS treatment she was receiving. 

While this treatment is still being studied and not yet FDA approved in the US, it is promising for those with MS fatigue who have tried other treatments and have not been able to beat the fatigue symptomsHowever, because it is off label it is not covered by insurance. Other treatments for fatigue can have daily side effects because they are taken daily. TMS is 3 days per week and for only 6 weeks. It is unclear how long the benefits of the treatment last so the treatment potentially may have to be repeated if fatigue returns. Because it causes neuroplastic changes in the brain, however, benefits seem to be lasting. For depression and OCD, benefits have been shown to last several months to a year.  

Side effects of TMS might include headache and neck pain which are usually mild and go away after the treatment is ended or after taking a mild pain reliever. There is a very rare risk of seizure induction so it should be avoided in patients who have uncontrolled epilepsy. It should also not be used if a person has implanted medical devices in the head or neck, vagus nerve stimulators, or other implanted devices you can discuss with your provider. Also, people with implanted metal in the head and neck should avoid TMS. Titanium implants are safe.  

At Hopemark Health, we are open to providing dTMS to patients with MS fatigue in collaboration with patients’ neurologists.  Due to it being off label, this treatment would not be covered by insurance at this time.  We would use the protocol outlined by the studies cited in this article and used on the patient who underwent the treatment in 2023 at Hopemark with success.  If you have questions, talk to your neurologist or schedule an appointment with one of our providers to learn more about if this treatment is appropriate for you. 

References

1200 628 January Robinson, PMHNP-BC

January Robinson, PMHNP-BC

January is a Psychiatric Nurse Practitioner (PMHNP-BC) who has been working with Hopemark Health for 5 years providing ketamine services. She completed the TRIPP-Certified Ketamine Assisted Psychotherapy Clinician Training in 2022 and MAPS MDMA-Assisted Therapy training in 2021. January is dedicated to patient centered, holistic care that connects the body, mind, and spirit.

Article by: January Robinson, PMHNP-BC