Expectations related to the use of theta burst stimulation protocols for pain relief. A systematic review

Pain treatment by repetitive transcranial magnetic stimulation (rTMS) of the primary motor cortex (M1) is generally based on the conventional high-frequency (HF) paradigm. Newer theta-burst stimulation (TBS) paradigms are increasingly being used instead of HF-rTMS in various therapeutic applications, such as the treatment of depression. The literature was analyzed until January 2025 to appraise the analgesic effects of various TBS protocols (intermittent TBS, iTBS, continuous TBS, cTBS, and prolonged protocols, piTBS and pcTBS) in the context of experimental pain provoked in healthy subjects or chronic pain experienced by patients. In experimental pain (19 articles), analgesic effects were mainly produced by pcTBS of M1. Conversely, in chronic pain (19 articles), pain was rather relieved by iTBS of M1 used alone or for priming HF-rTMS. However, the data reported to date are too few to conclude on the interest of iTBS compared to HF-rTMS. Shorter iTBS sessions open up prospects for "accelerated" procedures, expected in the field of pain. However, it will be necessary to precisely control the stimulation parameters (e.g. the number of pulses delivered per session per day or the interval between sessions) and to evaluate their impact on cortical excitability and connectivity.