TMS side effects are mostly mild and local: scalp discomfort and headache during the first week, and facial twitching during pulses. There is no anesthesia, no cognitive impairment, no memory loss, no weight gain and no sexual side effects. The serious risk is seizure, estimated at under 0.1 percent per treatment course and lower with proper screening. You drive yourself home after every session.
This page covers what you are likely to feel, what you are unlikely to feel, the one thing we worry about, and how safety is built into every course at our Palm Beach Gardens office. If you have been avoiding TMS because you worry it is harsh or risky, the evidence should reassure you.
Who it is for
Safety information matters to every TMS candidate, but it is decisive for people who have had bad experiences with medication side effects. If you stopped an SSRI because of sexual dysfunction, gained 20 pounds on mirtazapine or an atypical antipsychotic, or felt numb and foggy on everything you tried, TMS offers relief without any of those effects because it does not enter your bloodstream. It is also relevant for people weighing TMS against ECT, where memory loss and anesthesia are the main concerns, and for older adults and people with medical conditions who need to avoid drug interactions.
How it works
The magnetic pulse stimulates everything between the coil and the cortex: scalp skin, the muscles of the forehead and jaw, branches of the trigeminal and facial nerves, and finally the neurons we are targeting. Scalp sensation and muscle twitching come from the first three. They are expected, they are not harmful, and they fade as you acclimate. The pulse also, by design, makes cortical neurons fire. In a tiny fraction of cases that synchronized firing spreads and produces a seizure. Safety guidelines limit pulse frequency, intensity, train length and rest intervals to values that keep that probability very low, and every FDA-cleared protocol stays within them. Screening removes the people whose brains are most prone to spread: those with epilepsy, structural lesions, or seizure-threshold-lowering medications.
The estimated risk of seizure with rTMS is less than 1 per 30,000 sessions, or under 0.1 percent per treatment course, in patients screened according to safety guidelines.
Source: Rossi et al., International Federation of Clinical Neurophysiology safety guidelines, Clinical Neurophysiology, 2021
In the Deep TMS pivotal trial, the most common adverse events were application-site pain (about 25 percent) and headache; discontinuation for adverse events was under 5 percent and no seizures occurred.
Source: Levkovitz et al., World Psychiatry, 2015
A review of more than 30 years of TMS research found no evidence of lasting cognitive impairment, and several studies found small improvements in attention and processing speed after TMS courses for depression.
Source: Rossi et al., Clinical Neurophysiology, 2021
In the FDA-reviewed data for Deep TMS, the seizure rate across all clinical use was approximately 0.0038 percent per session.
Source: FDA 510(k) summary K122288, BrainsWay Deep TMS System, 2013
What to expect
In your first two or three sessions, expect the scalp under the coil to feel tender, like a bruise, and expect a mild tension-type headache afterward. Taking acetaminophen or ibuprofen 30 minutes before the session handles both for most people. Expect your eyebrow, eyelid or jaw to twitch with each pulse train. Expect loud clicking; you wear earplugs. By the end of week one most patients report that the sensation has become routine. You will have no sedation, so you can drive, work and exercise normally. Your technician asks about side effects at every session and a psychiatrist reviews them at least every two weeks.
Benefits
- No systemic exposure: nothing enters the bloodstream, so no interactions with your medications
- No cognitive side effects; studies show stable or slightly improved attention and memory
- No sexual dysfunction, weight gain, emotional blunting or sedation
- No anesthesia and no recovery period; you drive yourself to and from sessions
- Discontinuation rates for side effects in trials were under 5 percent
Risks and side effects
Common (more than 1 in 10): scalp discomfort or pain at the stimulation site, headache, facial muscle twitching during pulses, mild neck stiffness from sitting still. Uncommon (1 in 100 to 1 in 10): lightheadedness after a session, transient tinnitus if earplugs are not worn, increased anxiety or insomnia in the first week, tooth or jaw ache. Rare (under 1 in 1,000): seizure, estimated at under 0.1 percent per course and below 1 in 30,000 sessions; fainting during or just after a session, which is vasovagal and not a seizure; and in patients with bipolar disorder, a switch into hypomania or mania. There are no known long-term adverse effects after more than 30 years of use.
Cost and insurance
Side-effect management is included in your treatment; there is no extra charge for the technician's monitoring or the psychiatrist's reviews. If you develop a side effect that requires a change in your protocol, such as lowering intensity temporarily, that is part of the covered service. Ask our TMS coordinator if you have questions about what is included.
Side effects by frequency
| Side effect | How common | What we do about it |
|---|---|---|
| Scalp discomfort at coil site | Common, mostly week one | Pre-session pain reliever, minor coil adjustment, brief intensity ramp |
| Headache after session | Common, mostly week one | Acetaminophen or ibuprofen; resolves within hours |
| Facial or jaw twitching during pulses | Common, every session | Expected; stops when the pulse stops |
| Transient anxiety or insomnia | Uncommon, week one | Usually settles; afternoon sessions can help with sleep |
| Lightheadedness or fainting | Uncommon | Sit and hydrate; usually vasovagal, not a seizure |
| Hearing changes | Rare, preventable | Earplugs mandatory at every session |
| Hypomania or mania | Rare, mainly bipolar patients | Mood stabilizer on board; stop and reassess if it occurs |
| Seizure | Rare, under 0.1 percent per course | Screening, protocol limits, trained staff, emergency plan |
How TMS compares with the alternatives
| Concern | TMS | Antidepressants | ECT | Spravato |
|---|---|---|---|---|
| Cognitive or memory effects | None | Mild fog in some | Memory loss around treatments, usually temporary | Dissociation for 1 to 2 hours per dose |
| Sexual side effects | None | Common with SSRIs and SNRIs | None | None |
| Weight gain | None | Common with several classes | None | None |
| Anesthesia | None | None | General anesthesia every session | None, but 2-hour monitoring |
| Driving | Drive yourself | Usually fine | Driver required | No driving until next day |
| Most serious risk | Seizure, under 0.1 percent per course | Suicidality warning in young adults, serotonin syndrome | Anesthesia risk, cardiovascular events | Blood pressure rise, sedation, misuse potential |
Understanding the seizure risk
Seizure is the only serious adverse event associated with TMS, so it is worth understanding properly. The 2021 international safety guidelines, which pool decades of data from research and clinical use, estimate the rate at less than 1 per 30,000 sessions. Across a 36-session course that works out to under 0.1 percent, and the rate in patients without risk factors is lower still. TMS-induced seizures are brief, do not recur after the session, and have not been associated with lasting injury or the development of epilepsy.
Risk factors we screen for include personal history of epilepsy or seizures, structural brain lesions, significant head injury, medications that lower the seizure threshold (bupropion above 300 mg, clozapine, tramadol, high-dose stimulants, abrupt benzodiazepine withdrawal), sleep deprivation, alcohol withdrawal and active substance use. If any of these apply we either address them before starting or decide together that TMS is not the right option.
Contraindications
TMS is contraindicated with ferromagnetic metal or electronic implants in or near the head: aneurysm clips, cochlear implants, deep brain stimulators, vagus nerve stimulators, metallic fragments, and some older stents or coils. Dental work, titanium plates and non-magnetic implants are fine. Pacemakers and implanted defibrillators are a relative contraindication that usually resolves with cardiology clearance. Active epilepsy is a relative contraindication that we evaluate with neurology input.
Safety in special populations
Older adults
TMS is well tolerated in patients in their 70s, 80s and beyond. There are no drug interactions, no fall risk from sedation and no cardiovascular stress. Motor threshold tends to be higher with age, so intensity settings are higher, and we sometimes extend the course because older patients may respond more slowly.
Bipolar disorder
High-frequency left prefrontal stimulation can, uncommonly, trigger hypomania in people with bipolar disorder. We require a mood stabilizer for bipolar patients, monitor for sleep reduction and elevated mood at every session, and pause treatment if a switch begins.
Pregnancy
The magnetic field does not reach the abdomen, no drug is administered, and case series report normal outcomes. TMS is a reasonable option for significant depression in pregnancy when medication is a concern, decided together with your obstetrician.
Deep TMS in Palm Beach Gardens
Stedfast Psychiatry delivers Deep TMS at our Palm Beach Gardens office, 11641 Kew Gardens Ave, Suite 209, just off PGA Boulevard and I-95. Patients travel to us from Jupiter, West Palm Beach, Boynton Beach, Stuart and Royal Palm Beach, and most find the drive manageable because a Deep TMS session takes about 20 minutes and you drive yourself home. Call (561) 437-2199 to schedule a TMS consultation, or ask your current Stedfast provider for an internal referral. Our TMS coordinator handles insurance verification, prior authorization and scheduling so you can start as soon as approval comes through.
Frequently asked questions
Does TMS hurt?
It is uncomfortable rather than painful for most people, and the discomfort fades within the first week. The pulse feels like a firm tapping on the scalp, and the muscles of the forehead and jaw may twitch with each train. About a quarter of patients in trials reported scalp pain in the early sessions. A pain reliever before the session, a small adjustment of coil position, or a brief ramp-up of intensity over the first few days resolves it for nearly everyone.
Can TMS cause a seizure?
Rarely. The estimated risk is under 0.1 percent per treatment course and below 1 in 30,000 sessions when patients are screened and protocols follow safety guidelines. TMS-induced seizures are brief, self-limited and have not caused lasting harm in reported cases. We lower the risk further by excluding patients with active epilepsy, reviewing medications that lower the seizure threshold, and asking you to avoid sleep deprivation and heavy alcohol use during your course.
Does TMS cause memory loss?
No. This is the key difference from ECT. TMS does not affect memory, and neuropsychological testing before and after courses shows no decline. Several studies have found small improvements in attention, working memory and processing speed, which likely reflect recovery from depression rather than a direct effect of stimulation. There is no sedation, so there is no amnesia for the session itself.
Can I drive after TMS?
Yes. There is no anesthesia, no sedation and no drug administered, so you can drive yourself to and from every session. Most of our patients at Palm Beach Gardens come from Jupiter, West Palm Beach, Boynton Beach, Stuart and Royal Palm Beach and drive themselves. If you ever feel lightheaded after a session, which is uncommon, we ask you to sit for a few minutes before leaving.
Will TMS make me gain weight or affect my sex drive?
No. Weight gain, sexual dysfunction and emotional blunting are consequences of medications acting on receptors throughout the body. TMS acts only on the brain region under the coil and has no systemic effects. Patients often report that sexual function and appetite normalize as depression lifts. If you are continuing an antidepressant during TMS, that medication's side effects continue, but TMS adds none of its own.
Is TMS safe if I have a pacemaker?
Usually, but it requires review. The magnetic field is strongest within a few centimeters of the coil and falls off rapidly, so a device in the chest is well outside it. Guidelines treat pacemakers and implanted defibrillators as a relative contraindication. We ask for your device model and cardiology clearance before scheduling. Devices in the head or neck, such as cochlear implants, deep brain stimulators and vagus nerve stimulators, are absolute contraindications.
Are there long-term side effects from TMS?
None have been identified. TMS has been used in research since 1985 and clinically since 2008, and long-term follow-up studies have found no evidence of structural brain changes, cognitive decline, hearing damage when ear protection is used, or any delayed effect. The magnetic field is comparable to an MRI, and the induced currents are far below the level that could cause tissue damage.
What safety checks happen during my course?
Before the first session, a psychiatrist screens for contraindications and reviews every medication. On day one, motor threshold mapping sets your personal dose. At every session the technician asks about side effects, sleep, alcohol use and medication changes. A psychiatrist reviews your progress and side effects at least every two weeks. Emergency protocols and staff training for seizure response are in place even though we expect never to need them.
Where this treatment is offered
Conditions this treats
If you are in crisis, call or text 988 or go to the nearest emergency room. Educational content; individual results vary. Reviewed by Dr. David Husted, board-certified psychiatrist.