Repetitive Transcranial Magnetic Stimulation for Peripheral Neuropathic Pain: From Cortical Analgesia to...

Peripheral neuropathic pain (PNP) arises from lesions or diseases of the somatosensory system and remains difficult to treat because peripheral nerve injury is coupled to spinal, thalamic, cortical and affective network changes. Repetitive transcranial magnetic stimulation (rTMS) can engage cortical pain-modulation circuits without implantation or systemic drug exposure, but the field needs a clearer account of which peripheral neuropathic phenotypes, targets and trial designs can convert transient neuromodulation into clinically durable benefit. This narrative, non-systematic review synthesizes randomized trials, systematic reviews, consensus guidance and mechanistic studies through June 2026. The most defensible clinical signal is high-frequency stimulation of the primary motor cortex (M1) contralateral to the painful region. A 2026 meta-analysis assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework included nine randomized sham-controlled trials and 435 patients, and reported reduced pain intensity after rTMS (SMD, -1.11; 95% CI, -1.72 to -0.49). A separate 2026 pathology-stratified review found that postherpetic neuralgia (PHN) had the most consistent phenotype-specific evidence, whereas diabetic neuropathy (DNP), radiculopathy, brachial plexus injury and other peripheral neuropathies remained less certain. We propose an aetiology-stratified translational framework that separates three decisions often conflated in earlier reviews: confirmation of PNP, selection of cortical target and stimulation schedule, and documentation of multidomain response. At present, rTMS should be investigated as an adjunct to, rather than a replacement for, guideline-supported pharmacotherapy. Future studies should pre-specify sensory phenotype, mood and sleep status, target localization, maintenance schedules and responder definitions so that the feasibility and value of a phenotype-stratified rTMS framework can be tested reproducibly rather than assumed from short-term analgesic effects.