1 Recommendations

Guidance

Transcranial magnetic stimulation (TMS) has been evaluated for use during the aura before a migraine episode or at the start of a migraine episode, with the intention of stopping or reducing the severity of the episode ('treatment'); or at planned intervals, with the intention of reducing the frequency and/or severity of migraine episodes ('prevention').

1.1 Evidence on the efficacy of TMS for the treatment of migraine is limited in quantity and for the prevention of migraine is limited in both quality and quantity. Evidence on its safety in the short and medium term is adequate but there is uncertainty about the safety of long-term or frequent use of TMS. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research.

1.2 Patient selection should normally be done in specialist headache clinics and the procedure should only be used under the direction of clinicians specialising in the management of headache.

1.3 Patients should be informed that TMS is not intended to provide a cure for migraine and that reduction in symptoms may be modest.

1.4 Clinicians wishing to undertake TMS for treating and preventing migraine should take the following actions.

Inform the clinical governance leads in their NHS trusts.
Ensure that patients understand the uncertainty about the procedure's safety and efficacy and provide them with clear written information. In addition, the use of NICE's information for the public is recommended.
Audit and review clinical outcomes of all patients having TMS for the treatment and prevention of migraine (see section 7.1).

1.5 NICE encourages further research on TMS for treating and preventing migraine. Data should be collected for all patients not entered into controlled trials. Studies should describe clearly whether its use is for treatment or prevention. They should report details of patient selection and the dose and frequency of use. Outcome measures should include the number and severity of migraine episodes, and quality of life in both the short and long term. The development of any neurological disorders (such as epilepsy) in the short or longer term after starting treatment should be documented.