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Cited by 2,382Transcranial Magnetic Stimulation StudiesNeurological disorders and treatmentsPain Management and Treatment

Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014–2018)

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Lefaucheur, Jean-Pascal, Aleman, André, Baeken, Chris, Benninger, David H., Brunelin, Jérôme, Di Lazzaro, Vincenzo, Filipović, Saša R., Grefkes, Christian +23 more·2020·Clinical Neurophysiology
DOI 10.1016/j.clinph.2019.11.002
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Abstract

A group of European experts reappraised the guidelines on the therapeutic efficacy of repetitive transcranial magnetic stimulation (rTMS) previously published in 2014 [Lefaucheur et al., Clin Neurophysiol 2014;125:2150-206]. These updated recommendations take into account all rTMS publications, including data prior to 2014, as well as currently reviewed literature until the end of 2018. Level A evidence (definite efficacy) was reached for: high-frequency (HF) rTMS of the primary motor cortex (M1) contralateral to the painful side for neuropathic pain; HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC) using a figure-of-8 or a H1-coil for depression; low-frequency (LF) rTMS of contralesional M1 for hand motor recovery in the post-acute stage of stroke. Level B evidence (probable efficacy) was reached for: HF-rTMS of the left M1 or DLPFC for improving quality of life or pain, respectively, in fibromyalgia; HF-rTMS of bilateral M1 regions or the left DLPFC for improving motor impairment or depression, respectively, in Parkinson's disease; HF-rTMS of ipsilesional M1 for promoting motor recovery at the post-acute stage of stroke; intermittent theta burst stimulation targeted to the leg motor cortex for lower limb spasticity in multiple sclerosis; HF-rTMS of the right DLPFC in posttraumatic stress disorder; LF-rTMS of the right inferior frontal gyrus in chronic post-stroke non-fluent aphasia; LF-rTMS of the right DLPFC in depression; and bihemispheric stimulation of the DLPFC combining right-sided LF-rTMS (or continuous theta burst stimulation) and left-sided HF-rTMS (or intermittent theta burst stimulation) in depression. Level A/B evidence is not reached concerning efficacy of rTMS in any other condition. The current recommendations are based on the differences reached in therapeutic efficacy of real vs. sham rTMS protocols, replicated in a sufficient number of independent studies. This does not mean that the benefit produced by rTMS inevitably reaches a level of clinical relevance.

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  • Repetitive transcranial magnetic stimulation is well tolerated with few minor side effects.

    “rTMS is well tolerated with few minor side effects.26”

    From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [26]

    Section 2.3 (page not provided) says rTMS was well tolerated with few minor side effects in two studies of high-frequency stimulation of the left DLPFC for fibromyalgia. The citing sentence presents that finding as applying to rTMS generally, beyond the treatment and population described in the source. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • High-frequency repetitive transcranial magnetic stimulation of the left motor cortex is more effective in improving quality of life.

    “In contrast, HF-rTMS of the left motor cortex is more effective in improving quality of life.26”

    From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [26]

    Section 2.3 states that, in fibromyalgia, high-frequency rTMS of the left primary motor cortex is more efficacious for quality of life than left prefrontal stimulation. The citing sentence omits the fibromyalgia limitation, making the claim broader than the source supports. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Quality of life is improved in patients with fibromyalgia treated with high-frequency repetitive transcranial magnetic stimulation of the motor cortex, with an impact on fatigue.

    “Quality of life has been shown to be improved in patients with FM treated with high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) of the motor cortex, with evidence of an impact on fatigue.26”

    From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [26]

    Section 2.3 (page unavailable) reports improved quality of life in patients with fibromyalgia after high-frequency rTMS of the left motor cortex. Its evidence of improved fatigue, however, concerns stimulation of the left dorsolateral prefrontal cortex, not the motor cortex. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

  • High-frequency repetitive transcranial magnetic stimulation of the left dorsolateral prefrontal cortex is more effective in reducing pain.

    “HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC) is more effective in reducing pain.”

    From A Review of Movement and Functional Impairments in Fibromyalgia: Implications for Targeted Treatment (2025) · cites this paper as [26]

    Section 2.3 (page unavailable) says HF-rTMS of the left DLPFC is more efficacious for pain in fibromyalgia. The citing sentence omits that limitation and presents the finding as applying to pain generally; section 2.2 does not find a convincing DLPFC alternative for neuropathic pain. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Intermittent theta-burst stimulation (iTBS) is a validated, substantially abbreviated alternative that is noninferior to conventional 10-Hz rTMS for depression.

    “intermittent theta-burst stimulation (itBs) is a validated, substantially abbreviated alternative that is noninferior to conventional 10-hz rtMs for depression”

    From Feasibility, tolerability, and preliminary effectiveness of an accelerated bilateral intermittent theta-burst stimulation protocol in adults with posttraumatic stress disorder and comorbid depressive disorder following mild traumatic brain injury (2026) · cites this paper as Lefaucheur et al. 2020

    Section 10.3 reports that iTBS sessions take about 3 minutes versus more than 20 minutes for standard rTMS, and describes a large study finding left-prefrontal iTBS noninferior to conventional high-frequency rTMS for depression. But the guidelines say the evidence for iTBS remained insufficient to make a recommendation, so calling it a validated alternative overstates their conclusion. The supplied passages have no page numbers. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

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Authors
Lefaucheur, J.-P., Aleman, A., Baeken, C., Benninger, D. H., Brunelin, J., Di Lazzaro, V., Filipović, S. R., Grefkes, C., Hasan, A., Hummel, F. C., Jääskeläinen, S. K., Langguth, B., Leocani, L., Londero, A., Nardone, R., Nguyen, J.-P., Nyffeler, T., Oliveira-Maia, A. J., Oliviero, A., Padberg, F., Palm, U., Paulus, W., Poulet, E., Quartarone, A., Rachid, F., Rektorová, I., Rossi, S., Sahlsten, H., Schecklmann, M., Szekely, D., & Ziemann, U.
Affiliations
  • Université Paris-Est Créteil (FR)
  • University Medical Center Groningen (NL)
  • Ghent University (BE)
  • Centre Hospitalier Universitaire Vaudois (CH)
  • Lyon 1 Université (FR)
  • University of Belgrade (RS)
  • Forschungszentrum Jülich (DE)
  • Ludwig-Maximilians-Universität München (DE)
  • University of Geneva (CH)
  • University of Turku (FI)
  • University of Regensburg (DE)
  • Vita-Salute San Raffaele University (IT)
  • Sorbonne Paris Cité (FR)
  • Paracelsus Medical University (AT)
  • Centre Hospitalier Universitaire de Nantes (FR)
  • University of Bern (CH)
  • Hospital de Egas Moniz (PT)
  • Servicio de Salud de Castilla La Mancha (ES)
  • LMU Klinikum (DE)
  • Centre Hospitalier Universitaire Henri-Mondor (FR)
  • University of Messina (IT)
  • Central European Institute of Technology (CZ)
  • Hertie Institute for Clinical Brain Research (DE)
Corresponding author
Lefaucheur, Jean-Pascal
ORCID
Venue
Clinical Neurophysiology
Publisher
Elsevier BV
Published
2020-02
Volume
131
Issue
2
Pages
474-528
ISSN
1388-2457 (ISSN-L)
DOI
10.1016/j.clinph.2019.11.002
OpenAlex
W2997901555
Cited by
2,382
References
31
Citations by year
2026: 435 · 2025: 457 · 2024: 454 · 2023: 335 · 2022: 340 · 2021: 264 · 2020: 95 · 2019: 1
FWCI
18.21
Type
journal article
Language
en
Update notices
erratum (2020-05-01)
Open access
Licence
Locations
  • Clinical Neurophysiology (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Kölner Universitäts PublikationsServer (Universität zu Köln) (publishedVersion)
  • Ghent University Academic Bibliography (Ghent University) (submittedVersion, cc-by-nc-nd)
  • Archivio Istituzionale della Ricerca - Università Vita-Salute San Raffaele (submittedVersion, cc-by-nc-nd)
  • Portuguese National Funding Agency for Science, Research and Technology (RCAAP Project by FCT) (submittedVersion, other-oa)
  • HAL (submittedVersion)
  • BORIS (University Library Bern) (submittedVersion, cc-by-nc-nd)
  • University of Regensburg Publication Server (University of Regensburg) (submittedVersion)
  • Infoscience (Ecole Polytechnique Fédérale de Lausanne) (submittedVersion, cc-by-nc-nd)
  • IRIS (submittedVersion)
  • University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, cc-by-nc-nd)
  • RIMI (Institute for Medical Research, University of Belgrade) (submittedVersion, other-oa)
  • SERVAL (Université de Lausanne) (submittedVersion)
  • OPUS (Augsburg University) (submittedVersion, cc-by-nc-nd)
  • Use Siena air (University of Siena) (submittedVersion, other-oa)
  • VUBIR (Vrije Universiteit Brussel) (submittedVersion)
Funders
  • Ministry of Education, Science and Technological Development of Republic of Serbia
  • Fundação para a Ciência e Tecnologia
  • FEDER
Topics
  • Life Sciences › Neuroscience › Neurology › Transcranial Magnetic Stimulation Studies
  • Health Sciences › Medicine › Neurology › Neurological disorders and treatments
  • Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
Keywords
repetitive transcranial magnetic stimulation, treatment efficacy, neuropathic pain, depression, fibromyalgia, Parkinson's disease, multiple sclerosis spasticity, post-traumatic stress disorder, aphasia, dorsolateral prefrontal cortex, primary motor cortex, theta burst stimulation, evidence-based recommendations
MeSH terms
Mental Disorders, Humans, Nervous System Diseases, Practice Guidelines as Topic, Evidence-Based Medicine, Transcranial Magnetic Stimulation

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