TMS Therapy · Hayward, CA

The question almost everyone asks before their first session is some version of does it hurt. The honest answer is: it can. For most patients, the sensation is mildly uncomfortable for the first one to three sessions and then becomes increasingly tolerable. For some, it is sharper than that on day one. For a few, it never quite stops being annoying.

What I tell patients in my Hayward office is the same thing I’m going to tell you here. The goal of TMS is not to silently endure it. The goal is to make the treatment tolerable enough to finish — and finish well enough to feel better. Discomfort that gets in the way of completing the course is a problem we can usually solve in the chair, in real time. Discomfort that you don’t tell anyone about is a problem we can’t fix.

What TMS actually feels like

You sit upright in a clinic chair, awake, while a small coil rests against your scalp. No anesthesia, no sedation, no IV line. The technician calibrates the device to your individual motor threshold — the lowest power needed to make your hand muscles twitch — and then delivers thousands of focused magnetic pulses to the left dorsolateral prefrontal cortex over the next 3 to 40 minutes, depending on which protocol you’re on.^[1]

What you feel underneath the coil is a rapid tapping or knocking against the scalp. Patients describe it different ways: like a woodpecker, like a rubber band snapping, like a small finger drumming on the same spot. The tapping is the magnetic field rapidly switching on and off, which causes the scalp muscles and small nerves under the coil to twitch in time with the pulses. You will sometimes also feel small involuntary movements in the forehead, around the eye, or in the jaw.^[2]

The word “noninvasive” is technically accurate — TMS does not break the skin, require surgery, or alter consciousness. But “noninvasive” is not the same word as “painless.” Plenty of patients find the first sessions uncomfortable. The professionals administering TMS know this. The protocols and equipment are designed for it.

What the data says about who finds it tolerable

Across 93 placebo-controlled trials of TMS, active stimulation was associated with adverse events in about 29% of participants, compared with 14% on sham (placebo) treatment.^[3] The most common were headache, scalp discomfort, and brief facial twitching during stimulation. Importantly, the rate at which patients discontinued treatment because of side effects was nearly identical between active and sham: 2.5% versus 2.7%.^[3]

That last number matters more than the first one. It tells you that adverse events from TMS are real, but they’re rarely severe enough to make patients quit. Roughly 97 out of every 100 people who start a course finish it.

Newer protocols are designed in part to reduce discomfort. Intermittent theta-burst stimulation (iTBS) delivers the same effective dose in about 3 minutes instead of the standard 37.5. In the THREE-D non-inferiority trial of 414 adults with treatment-resistant depression, iTBS matched the older 10-Hz protocol on every efficacy measure — including remission and response rates — while cutting session time by more than 90%.^[4] Shorter sessions mean less cumulative sensation per visit.

Why the first few sessions are the hardest

Three things are happening in those early sessions that make them feel worse than the ones that follow.

First, your nervous system is being asked to do something it hasn’t done before. The scalp under the coil contains small sensory and motor nerves that respond to magnetic stimulation by firing. Until those nerves get used to the rhythm, the input feels novel — and novel sensations tend to register as more intense than familiar ones.

Second, your treatment is being calibrated. Your provider sets the device intensity at a percentage of your motor threshold — high enough to be therapeutic, low enough to be safe. In the first one or two sessions, your provider may also make small adjustments to the coil position to find the best spot on your prefrontal cortex. Both of these calibrations involve trial and error. Sensation often improves once the setup is dialed in.

Third, you’re learning what to expect. By session four or five, most patients know how to sit, where their head rests against the support, when to breathe through a sharper pulse, and when to ask for a break. The treatment feels predictable. Predictable discomfort is more tolerable than surprise discomfort, by a wide margin.

What can be adjusted in the chair

If the discomfort during a session is more than you can tolerate, your provider has a working list of things to try before reaching for stronger interventions. Here is what that conversation typically includes:

Coil position and angle. A small shift in where the coil sits on your scalp — even a few millimeters — can change which scalp nerves are activated. Sometimes the original placement is correct for stimulation but suboptimal for comfort, and a marginal repositioning resolves the issue without sacrificing efficacy.^[2]

Stimulation intensity. Your treatment intensity is set at a percentage of your individual motor threshold. If the protocol allows for it, your provider may briefly reduce the intensity, give you a few minutes to accommodate, then ramp back up. Almost everyone tolerates the full dose by the end of the course; the question in the first week is how to get there.

Pacing. Some protocols allow for short breaks between pulse trains. Standard 10-Hz rTMS already includes built-in inter-train intervals. If you need an additional brief pause to reset, ask for it.

Head support and cushioning. The chair, the head rest, the cushion thickness, and whether you sit slightly more upright or slightly more reclined all influence how the coil contacts the scalp. A small change in posture often quiets the sensation.

Pre-session analgesia. Many patients take an over-the-counter dose of acetaminophen or ibuprofen 30 minutes before their session, particularly in the first week. This is a low-risk intervention that meaningfully reduces headache likelihood for some patients. Ask your prescriber whether it’s appropriate given your other medications.

Headache: the most common complaint

If you’re going to get a side effect, headache is by far the most likely one. It’s the most frequently reported adverse event across every meta-analysis of TMS for depression, more common than scalp pain and substantially more common than anything more serious.^[3]

Most TMS-related headaches are mild to moderate, located either at the stimulation site or across the forehead, and resolve within an hour or two after the session. Standard over-the-counter pain relief works for the majority of patients. Headaches usually become less frequent and less intense over the first one to two weeks.

If you have a personal history of migraine, tell your provider before starting. Migraine isn’t a contraindication to TMS — most patients with migraine still tolerate treatment — but it does mean your provider will want to know your baseline headache pattern so they can recognize a meaningful change from it.

What to tell your provider immediately

Some sensations during or after TMS are routine and self-resolving. Others need a conversation, sometimes urgently. Here is the dividing line.

Tell your provider during the next session, before stimulation starts: headache that started after a session and lasted more than 24 hours, persistent scalp tenderness that doesn’t resolve by the next day, lightheadedness after standing up, sleep changes, or any new mood symptoms — anxiety, irritability, a feeling of being wired, or anything that feels different from your baseline.

Tell your provider immediately — by phone, or before leaving the clinic — if you experience: severe pain that doesn’t respond to over-the-counter analgesia, a headache that is sharply different in character from any you’ve had before, dizziness that does not pass within a few minutes, vision changes, confusion, weakness, faintness, panic, or any new neurologic symptom.

These last items are rare. They are not the typical TMS experience. But if they happen, your provider needs to know in real time so they can evaluate and adjust the plan.

The two safety considerations worth understanding

Most patients ask about two specific risks. Both are real, both are uncommon, and both are worth understanding before you start.

Seizure is the risk patients hear about most. It is also the one with the most reassuring data behind it. The 2021 international consensus from the IFCN — the global authority on TMS safety, with 35 expert co-authors — concluded that seizure risk with standard rTMS and theta-burst protocols, using current coils and traditional parameters, is low even in patients taking medications that act on the central nervous system.^[5] A 2022 review of 43,873 accelerated TMS sessions in 1,543 participants found one seizure across all sessions — a rate of roughly 1 in 44,000.^[6] Risk is concentrated in patients with personal or family history of seizure, certain medications that lower seizure threshold (bupropion at high doses, tramadol, certain antibiotics), and alcohol withdrawal. Your provider will screen for these before starting.

Manic or hypomanic switch is the second consideration, particularly relevant if you have a personal or family history of bipolar disorder. A 2024 network meta-analysis of theta-burst stimulation across 23 randomized trials found no significant increase in manic switch incidence with active TBS versus sham, but the absolute number of cases was small enough that monitoring still matters.^[7] Tell your provider during treatment if you notice a sudden surge in energy, decreased need for sleep without fatigue, racing thoughts, irritability, impulsivity, or anything that feels unusually elevated. These signals are why your team will check in with you every few sessions about mood, sleep, and energy — not just depression scores.

Who should think twice before starting TMS

Most adults with depression are candidates for TMS. But there are situations where the safety conversation needs to be longer. Tell your provider before starting if any of these apply to you:^[1][5]

You have a personal history of seizure or epilepsy. You have implanted metal hardware in or near your head — a cochlear implant, a deep brain stimulator, certain dental devices, aneurysm clips. You have a cardiac pacemaker or implanted medication pump. You have a history of significant brain injury or stroke. You are pregnant — TMS has less data in pregnancy than other treatments, and your provider may want to discuss alternatives or modifications. You have a history of bipolar disorder. You are currently using high doses of medications known to lower seizure threshold.

None of these is necessarily a hard stop. Most can be managed by adjusting protocols, lowering intensity, or extending monitoring. But your provider needs to know about all of them before the first session.

What discomfort is worth tolerating, and what isn’t

The honest answer to is the discomfort worth it depends on what TMS is offering you.

If you’re in the third or fourth medication trial of your current depressive episode, your odds of full remission on the next antidepressant are about 13%.^[8] If you switch to TMS, response rates in modern trials cluster around 40–55%, with remission around 25–35%.^[1] Among initial responders, roughly two-thirds remain in response at three months, half at six months, and just under half at twelve months without further treatment.^[9] Those numbers are the reason patients accept four to six weeks of in-clinic sessions and a tapping sensation against the scalp.

The discomfort worth tolerating is the kind that fades by session five and never gets in the way of completing your course. The discomfort worth talking about is everything else.

The bottom line

TMS can feel like tapping, knocking, pressure, or a small rubber-band snap against the scalp. For most patients, the sensation is uncomfortable for the first one to three sessions and then progressively tolerable. About 29% of patients report at least one adverse event during a course, but only 2.5% discontinue for that reason — nearly the same rate as patients on sham stimulation. Headache and scalp soreness are the most common issues, and both usually respond to coil-position adjustments, intensity changes, or a pre-session over-the-counter analgesic.

Serious adverse events — seizure, mania, persistent neurologic symptoms — are rare but real. They are why your provider screens you carefully before the first session and checks in on mood, sleep, and energy throughout the course. The seizure rate across more than 43,000 accelerated TMS sessions in modern studies is roughly 1 in 44,000.^[6]

If you are in Hayward or the East Bay considering TMS for treatment-resistant depression and you want to talk through what the sensation actually feels like, what your specific risk profile looks like, and whether the time commitment fits your life, that’s what a consultation is for.

Nefretiri Abat, JD, PMHNP-BC — Founder, Exxceed Wellness. Exxceed Wellness is a psychiatric practice based in Hayward, CA offering medication management, TMS therapy, SPRAVATO, and ketamine treatment for treatment-resistant depression, ADHD, anxiety, and related conditions. This article is for educational purposes and does not constitute medical advice. If you are considering TMS and want to talk through what to expect, schedule a consultation at exxceedwellness.com.