Transcranial magnetic stimulation
Magnetic pulses sent through the skull to change activity in one area of the brain. In schizophrenia, it has been tested for persistent voices and for negative symptoms.
At a glance
- Type
- Brain stimulation: magnetic pulses through the skull, without surgery
- Used for
- Tested for voices that persist despite medicine, and for negative symptoms
- Status
- In trials
- First used
- 1985, in research on the human brain
- Evidence
- EarlyHow evidence is rated
- Administration
- Sessions at a clinic, on weekdays for about 3 weeks. In a Dutch trial for voices, 15 sessions of 20 minutes
- Starts to work
- Trials measured the effect after about 3 weeks of sessions
- Common side effects
- Headache, discomfort or pain at the scalp, neck pain, very rarely a seizure
- Checks needed
- Screening before treatment for epilepsy and for metal or electronic implants in or near the head
- In Europe
- For schizophrenia, mainly in research. In Europe, rTMS is used mostly for depression, where the evidence is stronger
Clinical summaryFor health professionals
- Not a standard treatment: European expert guidelines (Lefaucheur 2020) found no definite or probable benefit in schizophrenia.
- Voices: moderate benefit over sham in a meta-analysis of 25 trials (Slotema 2014).
- Voices: no benefit over sham in a Dutch trial of 62 patients (Slotema 2011).
- Negative symptoms: no benefit over sham in the largest trial, 175 patients (Wobrock 2015).
- Headache more than twice as common as with sham (Cochrane, Dougall 2015). Seizures very rare.
- Screen for epilepsy and for metal or electronic implants in the head (Rossi 2021).
What it is
Transcranial magnetic stimulation (TMS) uses a magnetic coil held against the head. The coil sends pulses through the skull that change activity in the area of the brain beneath it. Given as a series of pulses over many sessions, it is called repetitive TMS, or rTMS. In schizophrenia, it has been tested for voices that persist despite medicine, and for negative symptoms, usually alongside medicine.1 It is not a standard treatment for schizophrenia.2
How it works
For voices, slow pulses, one per second, are aimed at the left temporoparietal area, on the left side of the head above and behind the ear.3 Slow stimulation is thought to calm activity in the area beneath the coil. For negative symptoms, fast pulses, ten per second, are aimed at the left dorsolateral prefrontal cortex, at the front of the brain.4
Brain scans suggest that the left temporoparietal area is not the main source of voices in everyone. A Dutch trial therefore also aimed the pulses at the area most active during each person’s voices, found with a brain scan. This did not work better.5
History
In 1985, researchers showed that the human brain can be stimulated through the skull with a magnetic coil, without surgery.6 In 2000, a small trial of 12 people with schizophrenia found that slow stimulation of the left temporoparietal area reduced voices compared with sham stimulation.3 Larger trials followed. In 2011, a Dutch trial of 62 people found no benefit over sham for voices,5 and in 2015, a German trial of 175 people found none for negative symptoms.4
How well it works
For voices, the results are mixed. A 2014 review of 25 trials, led by Dutch researchers, found a moderate benefit over sham, largest for slow stimulation of the left temporoparietal area. It found no effect on psychotic symptoms overall.7 Yet in the large Dutch trial, voices improved no more with real stimulation than with sham.5
A Cochrane review of 41 trials with 1,473 people found some benefit of temporoparietal TMS over sham, but rated all the evidence as very low quality.1
For negative symptoms, the largest trial found no benefit over sham after 3 weeks or later.4 A 2025 review of 17 smaller trials found a small benefit from fast stimulation.8 In these trials, people having sham stimulation also improved noticeably, which makes a real effect hard to detect.9
European expert guidelines from 2020 found no definite or probable benefit of rTMS in schizophrenia. Its benefit is clearer for depression.2
Side effects
Headache is the most common side effect. In the trials, it was more than twice as common with real stimulation as with sham. People did not stop treatment early more often with real stimulation.1 Discomfort or pain at the scalp, and neck pain, can also occur.10
The most serious risk is a seizure. It is very rare: about 7 in 100,000 sessions of fast stimulation, mostly in people with risk factors such as epilepsy.10
Administration
TMS is given at a clinic. In the Dutch trial for voices, people had 15 sessions of 20 minutes. The strength of the pulses was set for each person, as a share of the lowest strength that makes a muscle twitch.5 In the German trial for negative symptoms, sessions took place on 5 days a week for 3 weeks.4
Contraindications and cautions
Before treatment, people are screened for conditions that raise the risk. A history of epilepsy, or metal implants inside the skull, usually rule out TMS in research, though neither rules it out completely. Implants with magnets or electronics, such as cochlear implants or brain stimulators, can be affected by the pulses.10 There are no studies of TMS safety specifically in pregnancy.10 The treating doctor can advise on individual risks.
Alternatives
For voices that persist despite medicine: clozapine (opens in a new tab), CBT for psychosis (opens in a new tab), AVATAR therapy (opens in a new tab) and coping training (opens in a new tab).
What we don’t know yet
- Whether any form of TMS reliably helps voices or negative symptoms.
- Which settings work best: the speed of the pulses, the target in the brain and the number of sessions.8
- How long any benefit lasts.
