Case reports have suggested that rTMS may be beneficial in epilepsia partialis continua [87] and, more recently, in status epilepticus [88–90]. The magnitude of the antiseizure effect of rTMS is often reported as greater than that in some drug trials; the putative benefit could be related to the previously noted concept that low-frequency rTMS is believed to induce synaptic plasticity via a long-term depression-type mechanism, different from the mechanisms involved in ASD function [90]. Nevertheless, the relative benefit of rTMS versus pharmacotherapy has never been subjected to a careful clinical trial.

One recent case report described a patient with a worsening epilepsy syndrome, with medically refractory focal-onset seizures leading to several weeks of ICU management, requiring high doses of many ASDs [90]. Eventually, low-frequency rTMS applied over the active occipital epileptogenic focus led to a rapid and marked improvement in seizure control, stabilization of the progressively worsening epilepsy syndrome, and substantial improvement in cognitive and overall clinical status. {In this case, the authors also demonstrated a very favorable benefit/cost ratio, with the 6 months of earlier intensive treatment, including several admissions to a major medical center, generating bills of $938,800, while the 11 rTMS sessions were charged at a total of $4400 – under 0.5 % of the inpatient billing.} Subsequently, this patient remained seizure-free for over 9 months, with “maintenance” rTMS sessions roughly every 3 months [91].

These reports and trials suggest that rTMS may be a clinically effective (and possibly, cost-effective) treatment for (highly) selected patients with refractory focal status epilepticus or possibly multifocal epilepsy with a single primary active focus. rTMS represents a potential new therapeutic option for patients with refractory focal epilepsy and without the side effects of ASDs. To confirm and extend these findings, larger, well-controlled, randomized clinical trials will be necessary.