| Variables to assess before commencing rTMS |
| Variable | What to do if the variable is endorsed by the patient |
- History of epilepsy
- Family history of epilepsy
- History of seizure
- History of head trauma
- History of loss of consciousness
- History of stroke
- History of brain tumor
- History of traumatic brain injury
- Any implanted medical devices
- Any metal in the head
| - Determine with the patient the risk/benefit ratio of administering rTMS given the presence of risk variables.
- Inform the patient that the presence of 1 or more of these variables could increase the risk of rTMS-associated adverse effects including a TMS-associated seizure.
- Consider consultation with other health care professionals (eg, neurologist) to assess risks of possible rTMS-associated adverse effects before commencing treatment with rTMS.
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- Current use of medication(s) that lower seizure threshold
| - Document the medications including the drug name and dose. Use the information to create an individualized medication checklist and update this list at each rTMS session.
- Encourage the patient and their psychiatric provider to keep medications stable during the rTMS course and to inform the rTMS clinical staff of any changes in medication use.
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- Current alcohol/substance use
| - Document the type and amount of alcohol/substance consumed.
- Provide education on the effects of alcohol/substance use on rTMS.
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| Variables to assess at each rTMS session |
| Variable | Actions or considerations |
- Sleep the night before treatment
| If the patient endorses insomnia, then: - Assess the duration and severity of the insomnia.
- Provide education on sleep hygiene.
- If warranted (new onset or significant change in sleep pattern), consider rechecking motor threshold before commencing with rTMS treatment.
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| | - Document any medication changes and reconcile with the medication history before each treatment.
- Provide education to the patient that changes in medication could affect the motor threshold.
- If warranted (change in medication could alter seizure threshold), consider rechecking motor threshold before commencing with rTMS treatment.
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| Headache associated with rTMS | - Document the duration and severity of the headache.
- Provide reassurance and educate the patient that headaches tend to occur early in treatment and decrease with successive treatments.
- If appropriate, recommend over-the-counter analgesic medication.
- Instruct the patient to monitor the headache for resolution and report back to rTMS staff.
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| Neck pain associated with rTMS | - Document the duration and severity of neck pain.
- Adjust the patient's seating position and head position to enhance comfort.
- Provide neck support as needed (eg, pillow).
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| Pain/discomfort at stimulation site (scalp) | - Document the quality, duration, and severity of pain.
- Provide reassurance and education to the patient that pain at stimulation site tends to be transient.
- If appropriate, recommend over-the-counter analgesic medication.
- If appropriate, recommend or prescribe topical analgesic for application to scalp (eg, lidocaine gel).
- Make subtle adjustment to coil position.
- Slightly reduce magnetic field intensity.
- Instruct the patient to monitor the pain and report information at the subsequent rTMS session.
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| Scalp induration/irritation from rTMS coil | - Document the size and appearance of the erythema or edema at stimulation site on scalp.
- Provide education to the patient that redness is transient.
- Assess the coil temperature.
- Assess the coil contact on the scalp; adjust pressure if appropriate.
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| Induction of manic/hypomanic symptoms | - Monitor closely for treatment-emergent insomnia, anxiety, irritability, agitation; use standard mania assessment scales in susceptible individuals.
- Evaluate possible role of concurrent medications.
- Consider whether treatment with rTMS should be discontinued.
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| Hearing loss/tinnitus | - Assess for duration and severity of hearing loss/tinnitus in relation to rTMS sessions.
- Check that ear plugs are intact.
- Instruct the patient to monitor the hearing loss/tinnitus and report information to the rTMS staff.
- Refer the patient to an audiologist as needed.
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| Vasovagal presyncope or syncope | - Document the duration and severity of the symptoms.
- Reassure the patient that syncope is a possible, but rare side effect.
- Instruct the patient on adequate hydration prior to treatment.
- Monitor medication use associated with orthostatic hypotension.
- If the patient experiences syncope, stop the current rTMS session and adjust the patient's head to a downward position to increase cerebral perfusion.
- Check the patient's blood pressure and pulse before and after each treatment.
- Refer the patient to a health care provider (eg, primary care physician, cardiologist) as needed.
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| Seizure | - Stop the stimulation and remove the coil.
- Ensure the patient is safe and is breathing.
- Do not try to restrain the patient or put anything in the patient's mouth.
- When possible and the patient is safe, turn the patient to the side to minimize possible aspiration.
- When possible and the patient is safe, call emergency medical services (EMS).
- Document the seizure activity (including start and stop time).
- Discontinue treatment with rTMS pending medical evaluation.
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