Repetitive Transcranial Magnetic Stimulation for Central Neuropathic Pain: “Superficial” vs “deep” rTMS in a Randomized Trial

This content is intended for healthcare professionals and is provided for educational purposes only. Transcranial magnetic stimulation (TMS) is not broadly approved for the treatment of central neuropathic pain.

Central neuropathic pain remains a significant clinical challenge, with many patients experiencing limited relief despite long-term pharmacological treatment. In parallel, increasing attention has been directed toward neuromodulation approaches, including repetitive transcranial magnetic stimulation (rTMS), and whether different stimulation technologies provide meaningful clinical differences.

A multicentre, international, randomized, sham-controlled crossover trial by Bouhassira et al. (2024), published in PAIN, investigated this question by comparing “superficial” rTMS using a figure-eight coil and “deep” rTMS using an H-coil, both targeting the primary motor cortex.

The study included 51 patients with central neuropathic pain of at least six months duration. Using a crossover design, each patient received figure-eight coil stimulation, “deep” rTMS, and sham stimulation, allowing for within-patient comparison. Each intervention consisted of five daily sessions over one week, with treatment periods separated by approximately five to six weeks.

Both active rTMS approaches were associated with greater pain reduction compared to sham stimulation, supporting the role of motor cortex stimulation in modulating pain perception in this population. The overall magnitude of pain relief was similar between “superficial” and “deep” rTMS, indicating comparable outcomes across stimulation techniques within this study.

Differences emerged in the temporal profile of response. “Superficial” rTMS demonstrated earlier onset of pain relief, whereas “deep” rTMS showed a delayed onset but more sustained effects, with reported benefits lasting up to three weeks following the final stimulation session.

Both stimulation approaches were well tolerated, supporting the feasibility of these neuromodulation techniques in controlled clinical settings.

These findings contribute to the growing body of research on transcranial magnetic stimulation (TMS) in central neuropathic pain, suggesting that different coil technologies may produce similar overall effects while differing in onset and duration of response.

As a crossover randomized controlled trial, the study provides comparative insights within the same patient population. However, results should be interpreted within the study design and do not establish clinical recommendations or definitive comparative advantage between stimulation approaches.

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