Therapeutic Applications of rTMS in Migraine Prophylaxis.
Abstract
Migraine is one of the main causes of neurological disability, especially in young adults. Recent developments in preventive migraine therapies have improved outcomes for many patients, while highlighting the need for additional therapeutic options for those who remain refractory to pharmacological prophylaxis. Repetitive Transcranial Magnetic Stimulation (rTMS) has emerged as a promising neuromodulatory tool. We searched published literature for articles describing the efficacy of different rTMS protocols in the treatment of migraine. The literature search was conducted using PubMed and Scopus for articles published up to March 26, 2026. Twenty-four articles were categorized based on cortical targets (primary motor cortex [M1], dorsolateral prefrontal cortex (DLPFC), Vertex, Visual Cortex or Multifocal). High-frequency rTMS (HF-rTMS) targeting either the M1 or the left DLPFC demonstrated potential efficacy for specific goals such as reducing monthly migraine days, pain intensity, and medication intake. According to studies using neurophysiological data (obtained via transcranial magnetic stimulation-electroencephalography (TMS-EEG)), clinical improvement correlates with enhanced frontotemporal network connectivity and restored cortical plasticity. Guided rTMS stimulation through functional connectivity between the DLPFC and the pregenual cingulate cortex (PGC) may increase the precision of pain processing network modulation. Low-frequency rTMS (LF-rTMS) protocols also show potential benefits, including reductions in headache frequency, intensity, disability and medication use, although the supporting evidence is limited and derived primarily from small and uncontrolled studies. Multifocal rTMS paradigms showed promising efficacy in episodic migraine. Considerable heterogeneity in study design, stimulation protocols, and outcome measures limited the ability to draw reliable conclusions. Frequency and localization may be important determinants of clinical success. Future research should focus on network-based, personalized stimulation protocols to potentially increase long-term therapeutic benefit.