Psychogenic Non-Epileptic Seizures (PNES) Are NOT a Contraindication to TMS
PNES (pseudoseizures) are not listed as a contraindication to transcranial magnetic stimulation (TMS), and emerging evidence suggests TMS may actually be a therapeutic option for this condition. The established TMS safety guidelines focus on minimizing seizure risk in patients with true epilepsy, not psychogenic events 1.
Key Safety Framework
Established TMS Contraindications
The actual contraindications for TMS are 2:
- Absolute: Cardiac pacemakers, implanted electrical devices, pulmonary artery catheters with thermistors, intracranial clips
- Relative: True epilepsy and known intracortical pathology
Notably absent from this list: PNES, conversion disorders, or functional neurological symptoms.
Why PNES Differs from Epilepsy
PNES are dissociative/conversion disorders without abnormal electrical brain activity 3. The primary TMS safety concern—inducing true epileptic seizures—does not apply to PNES patients in the same way it does to epilepsy patients. The 2019 consensus guidelines on TMS safety explicitly state that "any factor that independently increases the risk of a seizure" warrants increased vigilance 1, but PNES does not increase true seizure risk.
Emerging Therapeutic Evidence
Paradoxically, TMS is being investigated as a treatment FOR PNES, not avoided in these patients:
- A 2018 case series demonstrated that high-frequency rTMS (10 Hz, 3000 pulses per session) targeting the right temporoparietal junction was well-tolerated in 7 PNES patients and resulted in decreased weekly seizure rates that persisted at 3-month follow-up 4
- Treatment was specifically designed to address the hypothesized hypoactivity in brain regions involved in PNES pathophysiology 4
Critical Caveat: One Case Report
A single 2025 case report described PNES developing after TMS treatment for depression 3. However, this represents:
- One isolated case among thousands of TMS treatments
- A temporal association, not proven causation
- The patient improved with acupuncture, suggesting a functional/psychogenic mechanism rather than TMS-induced brain injury
Practical Clinical Approach
If you have a patient with documented PNES who needs TMS for another indication (e.g., treatment-resistant depression):
- Proceed with standard TMS protocols—PNES is not a contraindication
- Ensure proper diagnosis: Confirm PNES via video-EEG showing typical events without epileptiform activity (distinguishing from true epilepsy is critical) 5
- Apply standard safety monitoring: Follow established TMS safety guidelines as you would for any patient 1
- Document baseline PNES frequency: Track episodes before, during, and after treatment
- Consider therapeutic benefit: The TMS may actually help reduce PNES frequency 4
Distinguish from True Epilepsy
If there is any uncertainty about whether seizures are epileptic versus psychogenic, obtain video-EEG confirmation before proceeding. True epilepsy is a relative contraindication requiring careful risk-benefit assessment 2, while PNES is not.
Bottom Line
The absence of PNES from established contraindication lists 2, 1, combined with emerging data showing TMS may be therapeutic for PNES 4, indicates this condition should not prevent TMS use. The theoretical seizure risk that guides TMS safety protocols applies to epileptic seizures, not psychogenic events. Standard TMS safety protocols are sufficient for patients with PNES.