TITLE
Left Dorsolateral Prefrontal Cortex rTMS in Alleviating MTBI Related Headaches and Depressive Symptoms

AUTHORS
Leung A; Metzger-Smith V; He Y; Cordero J; Ehlert B; Song D; Lin L; Shahrokh G; Tsai A; Vaninetti M; Rutledge T; Polston G; Sheu R; Lee R.

SOURCE
Neuromodulation. 21(4):390-401, 2018 Jun.

OBJECTIVE
Persistent mild traumatic brain injury related headache (MTBI-HA) represents a neuropathic pain state. This study tested the hypothesis that repetitive transcranial magnetic stimulation (rTMS) at the left prefrontal cortex can alleviate MTBI-HA and associated neuropsychological dysfunctions.

METHODS AND MATERIALS
Veterans with MTBI-HA were randomized to receive four sessions of either real (REAL group) or sham (SHAM group) high frequency rTMS delivered at 10 Hz, 80% of resting motor threshold and 2000 pulses per session at >24 and <72 hours apart. Pre-treatment, post-treatment 1-week and 4-week headache and neuropsychological assessments were conducted.

RESULTS
Twenty nine out of forty-four consented subjects completed the study. A two-factor (visit x treatment) repeated measures ANOVA showed a significant (p = 0.002, F = 11.63, df = 1) interaction for the average daily persistent headache intensity with the REAL group exhibiting a significant (p < 0.0001) average reduction (+/-SD) of 25.3 +/- 16.8% and 23.0 +/- 17.7% reduction in their numerical rating scale at the one-week and four-week post-treatment assessments in comparison to <1 +/- 11.7% and 2.3 +/- 14.5% reduction found in the SHAM group. In addition, a significant (p < 0.01) 50% and 57% reduction was found in the prevalence of persistent headache in the REAL group at the one-week and four-week assessments in comparison to 7% and 20% reduction found in the SHAM group. Furthermore, the REAL group demonstrated a significant (p = 0.033) improvement (from 22.3 +/- 6.4 at pre-treatment to 19.0 +/- 5.0 at post-treatment one-week) in the Hamilton Rating Scale for Depression score, while the SHAM group’s score remained largely unchanged (from 25.33 +/- 8.43 to 24.64 +/- 5.03) in the same time frame. This trend of improvement, although not statistically significant, continues to the post-treatment four-week assessment.

CONCLUSION
A short-course rTMS at the left DLPFC can alleviate MTBI-HA symptoms and provide a transient mood enhancing benefit. Further studies are required to establish a clinical protocol balancing both treatment efficacy and patient compliance.

Copyright ? 2017 International Neuromodulation Society.