Frequently Asked Questions

Frequently Asked Questions About TMS


When is TMS used?

Antidepressant medications and psychotherapy are the first line treatments for major depression in most cases. These treatments, however, do not work for all patients, and the sad reality is that antidepressants only provide remission in less than 30% of cases. In these instances, TMS might be used as an alternative treatment, or to augment antidepressant medications or psychotherapy. Patients who have failed to achieve an adequate response from antidepressants, or who are unable to tolerate medications due to intolerable side effects might want to consider TMS therapy.

Why does TMS work?

TMS has been shown to produce changes in neuronal activity in regions of the brain implicated in mood regulation, such as the prefrontal cortex. As each magnetic pulse passes through the skull and into the brain, this induces brief activity of brain cells underlying the treatment coil. TMS causes neurons to fire and release neurotransmitters that often do not work in a patient with depression or other conditions.


The frequency of pulse delivery also influences whether brain activity is increased or decreased by a session of TMS. Recent studies also suggest that stimulation over the left and right sides of the brain can have opposite effects on mood regulation.

Who administers TMS?

TMS is always prescribed by a TMS physician. The initial motor threshold is always determined by a TMS physician in conjunction with a highly trained TMS technician. The treatment itself is administered by the TMS technician under the supervision of the TMS physician.


The TMS technician or physician will always be present to monitor the patient during the treatment. The patient can stop a treatment at any time by asking the staff member present.

What happens during an TMS procedure?

Because TMS uses magnetic pulses, before beginning a treatment, patients are asked to remove any magnetic-sensitive objects (such as jewelry, credit cards). Patients may be required to wear earplugs during treatment for their comfort and hearing protection, as TMS produces a loud clicking sound with each pulse, much like an MRI machine. Patients are seated during each session of TMS in a comfortable chair that resembles a dentist’s chair.


During the first TMS session, several measurements are made to ensure that the TMS coil will be properly positioned over the patient’s head. Once this is done, the TMS coil is placed over the patient’s scalp. The TMS physician along with the TMS technician then measures the patient’s motor threshold, by administering several brief pulses. The motor threshold is the minimum amount of power necessary to make the patient’s thumb twitch, and varies from individual to individual. Measuring the motor threshold helps the physician personalize the treatment settings and determine the amount of energy required to stimulate brain cells.

Once the motor threshold is determined, the coil is then brought forward so that it rests above the front region of the patient’s brain. This may be on the right, left or center depending on the patients unique needs. Treatment is then commenced.  During the treatment, patients will hear a series of clicking sounds and will feel a tapping sensation under the treatment coil.

Motor threshold is not checked at every treatment but may be reassessed if there is concern it may have changed, for example, because of a change in medication.

How long is an TMS procedure?

TMS therapy involves a series of treatment sessions. Treatment sessions vary in length depending on the TMS coil used and the number of pulses delivered but typically last around 15-20 minutes. Patients receive TMS 5 days a week. A typical course of TMS is 4 to 6 weeks. However, this can vary depending on an individual’s response to treatment.

Do I need to be hospitalized for a course of TMS?

Unlike ECT, TMS does not require any sedation or general anesthesia, so patients are fully awake and aware during the treatment. There is no “recovery time”, so patients can drive home or return to work afterwards and return to their usual activities.

What are the side-effects of TMS?

TMS is well-tolerated and associated with few side-effects and only a small percentage of patients discontinue treatment because of these. The most common side-effect, which is reported in about half of patients treated with TMS, is light headaches. These are mild and generally diminish over the course of the treatment.  Over-the-counter pain medication can be used to treat these headaches.


About one third of patients may experience painful scalp sensations or facial twitching with TMS pulses. These too tend to diminish over the course of treatment although adjustments can be made immediately in coil positioning and stimulation settings to reduce discomfort. Blackhawk TMS is very conscientious about insuring the comfort of our patients at all times.

The TMS machine produces some noise and because of this earplugs are given to the patient to use during the treatment. However, some patients may still complain of hearing problems immediately following treatment. No evidence suggests these effects are permanent if earplugs are worn during the treatment. The newer equipment is much quieter than the earlier models so they are therefore very quiet with far less likelihood of hearing involvement.

TMS has not been associated with many of the side-effects caused by antidepressant medications, such as gastrointestinal upset, dry mouth, sexual dysfunction, weight gain, or sedation.

The most serious risk of TMS is seizures. However, the risk of a seizure is exceedingly low, at Blackhawk TMS we follow up-to-date safety guidelines that are designed to minimize the risk of seizures. The seizure risk of TMS is actually less than that of taking medications.

Who cannot get TMS therapy?

Patients with any type of non-removable metal in their heads (with the exception of braces or dental fillings, or implants), should not receive TMS. Failure to follow this rule could cause the object to heat up, move, or malfunction, and result in serious injury or death. The following is a list of metal implants that can prevent a patient from receiving TMS:


  • Aneurysm clips or coils
  • Stents in the neck or brain
  • Deep brain stimulators
  • Electrodes to monitor brain activity
  • Metallic implants in your ears and eyes
  • Shrapnel or bullet fragments in or near the head
  • Facial tattoos with metallic or magnetic-sensitive ink(rare)
  • Other metal devices or object implanted in or near the head

Who will benefit the most?

Existing evidence to date suggests that patients who are less treatment-resistant respond better to rTMS than those who are highly treatment-resistant. However, there is much yet to be learned about particular variables that may impact response to TMS. Researchers are presently conducting clinical studies to evaluate who will benefit most from TMS therapy. For example, there is a lot of interest in evaluating whether TMS with antidepressant medications is more effective than TMS alone.  In Europe TMS is being used for Alzheimer’s, Parkinson’s, Bipolar, OCD and a host of other conditions.  Currently the FDA has under consideration the use of TMS for OCD, ADHD and addictions.  Patients may request treatment for off label conditions with the understanding that insurance companies will not cover these and the patient is responsible for the entire fee.  If interested, our business office can discuss off label treatments and financing.

How can I get TMS treatment?

TMS is one of the brain stimulation treatments for depression and other conditions offered at Blackhawk TMS. Before scheduling you for treatment, you must first be evaluated by one of our TMS clinicians to determine if TMS would be safe and appropriate for you.

Want to learn more?

For more information call our main office for Danville and Mill Valley at 925-648-2650 or Napa office at 707-254-7000 and our friendly and knowledgeable staff will answer any questions you may have and help you to arrange a consultation to see if TMS therapy is right for you.