Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain. TMS Therapy has been shown to be safe, well-tolerated, and effective for the treatment of adult patients with depression who have not benefited from antidepressant treatment.

Because this treatment for depression involves delivering repetitive magnetic pulses, you may also hear it referred to as repetitive TMS or rTMS.

TMS is FDA-cleared for the treatment of depression, however, multiple clinical studies have also shown that TMS is a safe, well-tolerated, and effective treatment for conditions such as chronic pain and anxiety. If you have chronic pain, you may also suffer from depression and/or anxiety — “comorbidities” of your condition. While the use of TMS for chronic pain is “off-label,” we’ve found that the best course of action is to treat our patients as the sum of their parts and not simply view them as specific ailments to fix.
Anecdotally, we can tell you that our patients have experienced relief from the following:

• Pain

• Anxiety

• Depression

• PMS

• Irritable Bowel Syndrome

As with many treatments for depression, anxiety, and chronic pain, individual patients may respond somewhat differently to TMS, so the amount of benefit that any given patient will realize from TMS treatment is difficult to predict. However, the potential benefit of TMS is that it may lead to a significant decrease in symptoms of depression, anxiety, and chronic pain without the side effects or risks associated with treatments such as medication, surgery, or electroconvulsive therapy.

This is a complicated question. There have been multiple clinical trials using standard TMS for the treatment of major depressive disorder, and these have generally found that about ⅔ of patients respond (meaning they improved by at least 50%) and about ⅓ of patients experience remission (meaning they no longer meet the diagnostic criteria for major depressive disorder). These figures can be deceptive because of the arbitrary cut-off of a 50% improvement being considered a “responder.” A patient that improved by 45% may have felt that the treatment was quite helpful, but this patient would not be considered a “responder” according to the design of the study.

At TPM, we are confident that at least 80% of our patients will feel that the treatment was successful and worthwhile when it is completed. We also have the freedom to alter any protocol that does not seem to be producing the desired results, as opposed to the clinical trials, in which they are forced to stick with a single protocol to maintain uniformity throughout the study.

Again, this is a difficult question to answer precisely. In research studies, about ⅔ of patients maintained their response or remission 6-12 months after completing the initial course of TMS. The patients in these studies were not given any long term maintenance treatments, however. We offer maintenance treatments in addition to the initial series of TMS treatments as a way of prolonging the initial benefits. Unfortunately, there is inadequate research at this time to confidently state what the most effective and efficient protocol is for long-term maintenance with TMS.

You might not be approved for treatment if you:

• Have a nonremovable conductive metal implant in or around your head (brain stimulators, cochlear implants, vagus nerve stimulators, etc.)

• Have a cardiac pacemaker (except in very rare circumstances)

• Have experienced severe head trauma, a brain tumor, or increased intracranial pressure

• Have a history of seizures or a seizure disorder

• Are pregnant or are thinking of becoming pregnant

TMS is generally a very safe treatment, but there are potential risks that need to be considered. In very rare circumstances, people undergoing TMS have had seizures, but the incidence is very low — about 0.1%. For perspective, you’re almost as equally likely to drown and twice as likely to die of a food-borne illness.

Side effects are generally mild to moderate and improve shortly after an individual session and decrease over time with additional sessions. They may include headache, scalp discomfort at the site of stimulation, tingling, spasms or twitching of facial muscles, and lightheadedness. You should be able to resume your daily activities right after treatment.

There are numerous treatments for depression other than TMS, such as antidepressant medication, psychotherapy (eg, “talk therapy,” such as cognitive behavioral therapy), exercise, dietary changes, ketamine infusions, intranasal esketamine, and electroconvulsive therapy (ECT). There are also numerous other treatments for chronic pain, including medications, physical therapy, ketamine infusions, interventional treatments (epidural steroid injections, nerve ablations, spinal cord stimulators, etc.), trigger point injections, acupuncture, chiropractic, mind-body techniques, and nutritional changes. Many of the people interested in TMS will have already tried some, if not all, of these other options prior to seeking out TMS as a possibility.

During your first session, you will be seated in the TMS treatment chair and a white cap, similar to a swimmer’s cap, will be placed on your head. We will take some measurements of your head in order to generate an initial estimated “map” of your underlying cerebral cortex in order to determine the proper locations to deliver the magnetic pulses. The next step is to determine your “motor threshold,” which is the intensity of the magnetic field needed to stimulate the motor cortex of your brain enough to cause your hand to move. The motor threshold (MT) is then used to guide the dosage (intensity of the magnetic pulses) needed to stimulate other parts of the brain. Once the MT is determined, this location is used to estimate the location of the dorsolateral prefrontal cortex (DLPFC), which is the spot that is stimulated in the treatment of depression. In the vast majority of cases, this will all be taking place on the left side of your head. Once we have completed the mapping and MT determination, we will start your first treatment. During subsequent sessions, we usually will not need to repeat the mapping or MT determination, so we will be able to start your treatment session more quickly.

The first session will be much longer than the subsequent sessions because of the MT determination and mapping as described above. The first session will probably last about 45 minutes for most people. Subsequent sessions will usually last about 25 minutes with about 17 minutes of actual TMS.

You’ll sit in a chair in a relaxed position. When the magnetic pulses are delivered, you’ll hear a clicking sound and feel a tapping sensation. While some people describe the initial treatments as uncomfortable, the general consensus is that it’s fairly easy to get used to.

We encourage you to relax and rest during the treatments. However, you may also read from your smartphone during the treatments if you wish. Please try to avoid reading anything particularly stressful or scary, however. Relaxing puzzle apps are a good way to distract yourself and pass the time (we have some suggestions).

In most cases, patients have daily sessions, 5 days per week (Monday-Friday). There may be certain cases in which we modify a protocol based on a particular patient’s needs.

The standard treatment regimen for depression consists of 30 daily sessions (5 days per week for 6 weeks), followed by 6 maintenance sessions (3 sessions the 1st week, 2 sessions the 2nd week, and 1 session the final week). This is the protocol that will be used for people who are using their insurance coverage for their TMS treatment.

Our unique protocol for pain will generally involve 30 daily sessions (5 days per week for 6 weeks), followed by 12 weekly maintenance sessions.

TMS is an investment in your future health. We can’t put a price on what it personally means for you to potentially improve your daily life. You are the best judge of what your current depression, anxiety, and pain is costing you.

That said, we can give you the following numbers if insurance does not cover your treatment:

• One-time mapping: $400

• Treatment sessions: $250

• Protocol: mapping, 30 treatment sessions, 6 taper-off sessions

• Total for pay-as-you-go: $9,400

For patients who opt to invest in a complete protocol upfront, we’ve created a discounted rate:

• $5000 for mapping, 30 treatment sessions, and 6 taper-off sessions

Additional/ongoing maintenance treatments are $250/session.

​​​​​​​*Patients who are referred to Thunder Pain Management and are not currently established with the practice will need to schedule a new patient appointment. Cost and coverage of this will vary based on your insurance.

Thunder Pain Management is committed to helping people in pain. That may sound hokey or ideological, but it’s a mission on which we founded ourselves and an ideology we’ve strived to continue. In early 2022, as we were getting the practice ready to bring in TMS, Dr. Thunder met Anthony Barker, the inventor of TMS. Much like the scientists who discovered insulin and refused to patent it so that it could be widely available, Dr. Barker did not patent TMS. As an English citizen covered by a universal healthcare system, he was understandably distraught by the situation in the United States and the cost now associated with TMS.

We made a promise to Dr. Barker that we would do our best to provide TMS to as many people as possible.
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We encourage you to research the current rates for TMS at Fair Health Consumer. The billing codes are 90868 for mapping and 90869 for each session.

Possibly. There are multiple criteria that need to be met before insurance will pay for TMS. Companies vary, but requirements are generally as follows:

1. The patient must have a diagnosis of severe major depressive disorder as measured by a depression rating scale.

2. The patient must have failed to respond to multiple antidepressant medications, usually between 2-4 medications depending on the insurance company. Some insurances require that the medications be from different classes, and some insurances may require a trial of an augmentation medication, such as an antipsychotic or a mood stabilizer.

3. The patient must have had an “adequate course” of psychotherapy (eg, cognitive behavioral therapy), and have failed to respond adequately. These are usually weekly sessions, so this would be about 3 months of therapy.

Keep in mind that when using insurance, all copays, co-insurance, and deductibles will apply. The numbers when going this route may look something like this:

• 12 sessions of therapy (often not covered by insurance): 12 x $150 = $1800

• $25 copays for TMS: $25 x 37 = $925

• $30 copays for TMS: $30 x 37 = $1110

• $50 copays for TMS: $50 x 37 = $1850

If you’re confused, this video should help clear things up.

Although there is a good chance that TMS will be helpful for you, there will inevitably be people for whom TMS is ineffective. If TMS is not effective for you initially, Dr. Thunder may try altering your protocol to see if a different approach may work better for you. It is possible that there may be an additional charge for this, depending on the circumstances.

If TMS continues to be ineffective for you, Dr. Thunder will discuss switching course or augmenting your therapy with other treatments, such as those listed above in the WHAT OPTIONS ARE THERE OTHER THAN TMS? section. Our primary goal is to help you feel better.