Treatment option: transcranial magnetic stimulation (TMS)
Clinical and at-home applications
Transcranial magnetic stimulation or TMS is an established and FDA approved treatment for depression. If you live in a major city, you’ll likely find an abundance of clinics providing this treatment.
If you went to such a clinic, you would likely return five days a week for four to six weeks. At each visit, your treatment would last about 30 minutes.
During a treatment, large electromagnets would generate a magnetic field at a specific frequency, and this field would act on the neurons principally in your left prefrontal cortex. (This is an area that may become under-active in depression, or in post-concussion syndrome or the depression one falls into during post-concussion syndrome).
TMS makes neurons fire at the same frequency as the electromagnetic wave they receive, thus producing brainwaves at the same frequency. While it’s a crude comparison, you can think of TMS as a jump-starter for your brain. The general idea is that by re-activating certain regions of your brain every day for about a month, those regions will regain the ability to regulate themselves.
TMS works for many people with depression (and with other conditions including migraine and PTSD). Symptoms of depression are often alleviated for a year or more after a month of treatment.
There are several new devices for delivering TMS treatment at home. I’ll cover this option under “My experience with TMS” below.
Getting clinical TMS covered by insurance
In the United States, clinical TMS is usually provided as a treatment for depression, not for post-concussion syndrome or traumatic brain injury (that’s usually considered an “off-label” use). It usually won’t be covered by your insurance unless you get a diagnosis for depression. Fortunately, that diagnosis is usually easy to get, in part because depression is a common downstream condition produced by a brain injury and/or the aftermath of dealing with that injury (including, ironically, the very depressing aspects of dealing with insurance coverage for the care you need).
In alignment with my goal of providing you complete information, even if I don’t think something is a good idea, I should mention that if you have, say, $10,000 to burn, you can seek out a clinic that will perform TMS on someone with a brain injury without a diagnosis of depression. These private clinics don’t take insurance and therefore don’t answer to insurance companies (or the mainstream medical community). Many of them are run by practitioners known as chiropractic neurologists, and TMS is just one of many treatments they may provide, typically as part of an expensive two-week intensive treatment.
My experience with TMS
I have never received clinical strength TMS, so I can’t speak to it from direct experience. However, I use a closely related technology called pulsed electromagnetic field (PEMF) therapy almost daily.
I was considering doing a round of clinical TMS when I discovered a device I could use at home called the NeoRhythm, and I opted to try that instead. It operates on the same principal as TMS, but it uses around 10,000 times less electricity than a clinical TMS machine (in many ways, that seemed like a good thing to me).
When I reached out to TMS clinics to ask about their assessment process, I was told they wouldn’t evaluate my brain’s waves, and that the frequencies they applied to me would be the same frequencies they applied to anyone. Hearing this, I thought of the people with brain injuries who haven’t been helped by TMS, and guessed that this lack of personalization might be to blame (along with the major differences in the profiles of patients including their levels of depression independent from their brain injury).
With the NeoRhythm, I use the Improve Sleep mode (a mix of slow waves including Delta) before bed. During the day, I’ve used the Energy & Vitality mode (a mix of higher frequency waves, including Gamma) while working. I’ve also used that mode after training, and it seems to keep me from tipping too far into overstimulation. As with anything else I mentioned here, “your mileage may vary.”
There are other at-home TMS and PEMF devices that I have no direct experience with. New devices are emerging rapidly. One that looks promising for depression in particular is Flow, though it may not be available yet in your country.
Incidentally, one of the things that helped me figure out which frequencies my brain might benefit from (via TMS) was doing a complete neurofeedback assessment with a licensed psychiatrist who runs a neurofeedback clinic. Which brings us to…
Complementing TMS with neurofeedback training
While TMS is great for symptom alleviation, and while it might also help your brain retrain itself over time (although the mechanism for that is less clear), neurofeedback training can help your brain learn how to produce the proper functional brainwaves—to be alert when you want be alert, to be calm when you want to be calm, for instance.
I view TMS and neurofeedback as complementary treatments. TMS provides an external locus of control, and neurofeedback helps you develop an internal locus of control.
Here’s a relevant quote from the Wikipedia page on neurofeedback that mentions a study linking the effectiveness of doing the two treatments in a complimentary way.
In 2010, a study provided some evidence of neuroplastic changes occurring after brainwave training. Half an hour of voluntary control of brain rhythms led in this study to a lasting shift in cortical excitability and intracortical function. The authors observed that the cortical response to transcranial magnetic stimulation (TMS) was significantly enhanced after neurofeedback.
As with TMS, neurofeedback was once something you could only access in a clinical setting that was highly inconvenient. A technician had to attach all the electrodes to your head (that alone might take 30 to 60 minutes) and this meant that doing the training was a major ordeal. You might go to the clinic three days a week, so the frequency and volume of training was also highly constrained.
Today you can do neurofeedback training at home with relative ease—every day, twice a day if you want. The device I currently use for this purpose is the Muse headband in tandem with the Myndlift application, under the supervision of a trained and licensed professional.
That said, neurofeedback clinics are still available and remain an option if home training doesn’t yield results. I also think they’re a good place to start when looking for someone to supervise your home training because they’re staffed with experienced technicians, psychiatrists, etc.
To learn more about neurofeedback training, see “Treatment option: neurofeedback training.”
Wrapping up
Transcranial magnetic stimulation is an established treatment for depression, and depression is something TBI patients often suffer from (for a variety of reasons, many of which are connected to the ways the medical system fails TBI patients). Your insurance company won’t cover TMS for TBI, but it will cover it as a treatment for depression.
You can access TMS at a clinic, but you could also consider starting with a home device such as the NeoRhythm. Unlike a TMS clinic, which may apply one frequency to your prefrontal cortex, the NeoRhythm offers a broad spectrum of frequencies that can help you down-regulate or up-regulate.
At least one study shows that TMS and neurofeedback are complementary treatments, so if you’re doing TMS, it might make sense to do neurofeedback in parallel.
As with TMS, neurofeedback can either be accessed at a clinic, or be done at home using a Muse headband and the Myndlift app under the supervision of a medical professional. TMS can provide you with a pivotal external locus of control, while neurofeedback helps you develop an internal locus of control.
Brainwave is an informational resource for people whose symptoms haven’t resolved after a concussion or mTBI. I endeavor to present this information in a clear and concise way, spelling out what’s backed by science and what remains unknown. Nothing here is meant as a substitute for professional medical advice, diagnosis, or treatment. I am not a physician or a healthcare practitioner of any kind; I’ve simply had a lot of sports-related concussions and had to learn this stuff the hard way. If you found this information helpful or know someone who might benefit from it, please share and subscribe to Brainwave.