At the New York Headache Center, we have been using fMRI-guided repetitive Transcranial Magnetic Stimulation (rTMS) to treat chronic migraine, posttraumatic headaches (PTH), pain syndromes, and neurological disorders. This approach uses functional MRI (fMRI) to precisely target brain regions involved in pain and mood regulation, enhancing treatment outcomes. A recent study published in The Journal of Neuropsychiatry and Clinical Neurosciences (JNCN Study) by researchers at Kaizen Brain Center in La Jolla, California, provides compelling evidence supporting this method in the treatment of PTH following traumatic brain injury (TBI). The study compared standard rTMS to fMRI-guided TMS, showing data on headache symptom improvement that aligns with our clinical experience.

PTH is the most common chronic symptom following mild-to-moderate TBI, often accompanied by depression and anxiety, which severely impact quality of life. Currently, there are no FDA-approved pharmacological treatments specifically for PTH. rTMS is a non-invasive technique that is FDA-approved for the treatment of anxiety and depression. For these indications, rTMS is directed at the left dorsolateral prefrontal cortex (DLPFC). The researchers treated PTH patients with rTMS also targeting DLPFC region. However, DLPFC is a fairly large area and the fMRI can help find a more specific region within left DLPFC that has the most anomalous connections to the rest of the brain.

In the discovery phase, 21 patients with PTH and depression received standard rTMS. While significant improvements were observed in depression and anxiety, the functional impact of headache (FH) did not significantly decrease, though over half reported reduced headache severity or frequency. Here, fMRI was critical in some patients, enabling individualized network-based targeting by analyzing resting-state brain connectivity. This helped identify specific neural networks, like the default mode or dorsal attention networks, tailored to patients’ symptoms, such as depression with anxiety or anhedonia. An exploratory analysis using normative fMRI data from a human connectome database further pinpointed a DLPFC coordinate (-26, 36, 42) where increased functional connectivity correlated with better headache outcomes.

In the translational phase, seven patients were treated at this precise coordinate, guided by the fMRI-derived insights from the discovery phase. They experienced significant reductions in FH (16% decrease) after four weeks, alongside faster improvements in depression and anxiety within one to two weeks. The use of fMRI to map brain networks and refine targeting likely contributed to the enhanced outcomes compared to the earlier phase, suggesting a potential dual-benefit treatment for PTH and mood disorders.

Despite limitations like a small sample size and the need for randomized controlled trials, these findings highlight rTMS, enhanced by fMRI-guided targeting, as a promising tool for PTH management. The protocol used in this study is different from what we do in our practice. Without fMRI data, we usually stimulate at least three areas – DLPFC, as well as bilateral motor or occipital cortex.  fMRI often suggests other regions as well. It is possible that stimulating more than one area may yield better results. Other variables that have not been worked out yet are the frequency of treatments needed (we find that once a week often is sufficient) and stimulation parameters – high frequency vs low frequency and vs theta-burst stimulation.