What are the exclusion criteria for Transcranial Magnetic Stimulation (TMS)?

Exclusion Criteria for Transcranial Magnetic Stimulation (TMS)

Patients with certain risk factors should be excluded from TMS treatment due to potential safety concerns and increased risk of adverse events.

Primary Exclusion Criteria

• Implanted metallic hardware in or near the head: Patients with metal implants such as cochlear implants, aneurysm clips, brain stimulators, or other metallic hardware in or near the head should be excluded due to potential interaction with the magnetic field 1, 2

• Seizure risk factors: Patients with history of epilepsy, recent stroke, head trauma, or other conditions that lower seizure threshold should be excluded as TMS may trigger seizures 1, 3

• Implanted electrical devices: Patients with cardiac pacemakers, vagus nerve stimulators, deep brain stimulators, or other implanted electrical devices should be excluded due to potential interference with device function 1, 2

• Skull defects: Patients with skull defects or craniotomy sites should be excluded as the altered skull integrity may change the electrical field distribution 3

• Pregnancy: Pregnant women are typically excluded from TMS treatment due to limited safety data in this population 1

Medication-Related Exclusion Factors

• Medications that lower seizure threshold: Patients taking medications that significantly lower seizure threshold require careful evaluation, including:

  • Certain antidepressants at high doses
  • Stimulants
  • Antipsychotics that lower seizure threshold
  • Tramadol
  • Bupropion (especially in nicotine treatment) 3

• Substance use considerations: Active substance use that may increase seizure risk, including:

  • Cocaine use
  • Alcohol withdrawal
  • Benzodiazepine/barbiturate use or withdrawal in opioid users 3

Condition-Specific Considerations

• Unstable medical conditions: Patients with unstable cardiac disease, recent stroke, or other unstable neurological conditions should be excluded 1

• Severe psychiatric conditions: Patients with acute psychosis or severe psychiatric instability that would interfere with treatment compliance 4

• Specific neurological conditions: Patients with increased intracranial pressure or recent neurosurgery should be excluded 1

Implementation Guidelines

• Pre-TMS screening: All patients should undergo comprehensive screening for exclusion criteria before initiating TMS treatment 5

• Documentation: Clear documentation of the absence of exclusion criteria should be maintained in patient records 3

• Monitoring: Even in patients without exclusion criteria, careful monitoring during TMS sessions is essential to detect any adverse effects 5, 1

Special Considerations

• Relative contraindications: Some conditions may represent relative rather than absolute contraindications, requiring individualized risk assessment:

  • History of mild head trauma without seizures
  • Family history of epilepsy
  • Medications that slightly lower seizure threshold 1

• Pediatric applications: Additional caution is needed when considering TMS in pediatric populations, with more stringent exclusion criteria 1

Common Pitfalls

• Inadequate screening: Failure to thoroughly screen for all potential contraindications before initiating TMS 5

• Overlooking medication interactions: Not considering the full medication profile and potential interactions that may increase seizure risk 3

• Ignoring substance use history: Failing to assess recent substance use that may increase risk of adverse events 3

• Misinterpreting relative contraindications as absolute: Some contraindications may be relative rather than absolute, requiring clinical judgment rather than automatic exclusion 1