Most people keep taking their usual medications, including antidepressants, during TMS. Today TMS is very often given alongside medication, and some FDA clearances, such as those for depression in adolescents aged 15 to 21, describe it as an add-on ("adjunct") treatment. What the TMS team does need is a complete, accurate list, because a few medications and situations affect seizure risk, and some may affect how well TMS works.
The most important rule: do not start, stop or change a medication because of TMS without talking to the prescriber first. Stopping some drugs suddenly is itself a seizure risk. Below is what the evidence says about antidepressants, the medications that come up in safety screening, the research on benzodiazepines and stimulants, and what to bring to your consultation.
Antidepressants: usually continued
The early landmark trials studied TMS in people who were not taking antidepressants. The pivotal 2007 NeuroStar trial enrolled medication-free patients, and the 2011 federal rule that classified TMS devices still describes patients "currently not on any antidepressant therapy". That wording reflects the original studies, not current practice; later FDA labels are broader.
Since then, TMS has commonly been given on top of medication:
- In the THREE-D trial of 414 adults, which led to the clearance of theta-burst TMS, participants stayed on stable antidepressant doses.
- The adolescent clearances from 2024 onward are explicitly "as an adjunct", meaning alongside antidepressant treatment.
- In a one-year follow-up study of people who had completed a TMS course, patients stayed on antidepressants.
Whether adding TMS to medication works better than TMS alone is a separate research question; Dr. Lewis reviews it in combining TMS with medication. For practical purposes, most psychiatrists keep a stable antidepressant regimen in place during a course, so that if things change, it is clear why. If you have been wondering whether to come off a medication that has not helped, raise it at your consultation and plan it with your prescriber; see how to talk to your provider about changing medications.
Why medications come up in TMS screening
The main serious risk of TMS is a seizure, and it is rare. In a large survey, when TMS followed published guidelines in people without known risk factors, the rate was fewer than 1 seizure per 60,000 sessions. Risk rises with patient risk factors such as epilepsy or brain lesions, and FDA guidance also asks teams to monitor people taking medications that lower the seizure threshold, which is why screening asks about both.
Two key sources differ in emphasis, and it is worth knowing both:
- FDA's 2011 guidance for TMS devices asks for close monitoring of patients taking "tricyclic antidepressants, neuroleptic medications, or other drugs that are known to lower the seizure threshold".
- The 2021 international safety guidelines say earlier caution about such medications is no longer supported by the data, because seizure rates are so low even though most TMS patients take medications that act on the brain. They still recommend documenting all medications and other risk factors.
In practice, that means a medication on the list below is usually a reason for a closer look and a conversation, not an automatic "no".
Medications and situations the team will ask about
| Medication or situation | Why it matters | What usually happens |
|---|---|---|
| Tricyclic antidepressants (for example, amitriptyline, nortriptyline) | Named in FDA's TMS guidance as lowering seizure threshold | Dose reviewed; monitoring |
| Antipsychotics ("neuroleptics") | Named in FDA's TMS guidance | Dose reviewed; monitoring |
| Bupropion (Wellbutrin) | Its own label says it can cause seizures and the risk is dose-related | Dose and other risk factors reviewed with your prescriber |
| Prescription stimulants (for example, Adderall) | Label says stimulants may lower the convulsive threshold | Reviewed with your prescriber |
| Cocaine, MDMA or other street stimulants | Listed as seizure-threshold factors in the 2021 safety guidelines | Must be disclosed; may delay TMS |
| Alcohol withdrawal or heavy drinking | Listed as seizure-threshold factors | Discuss honestly; plan before starting |
| Stopping a benzodiazepine, alcohol or anti-seizure drug suddenly | Bupropion's label contraindicates it during abrupt discontinuation of alcohol, benzodiazepines, barbiturates or antiepileptic drugs | Never stop on your own; taper with prescriber |
| Transplant drugs cyclosporine or tacrolimus | Listed in the 2021 safety guidelines | Specialist input |
Alcohol deserves a special word. In the deep TMS pivotal trial, the one seizure that occurred was attributed to heavy drinking the night before, which the patient had not mentioned, and possible alcohol withdrawal. Telling the team about drinking is a safety step, not a confession. Our page on caffeine, alcohol and sleep during TMS has more.
Benzodiazepines: a research question, not a rule
Benzodiazepines such as lorazepam (Ativan), clonazepam (Klonopin) and alprazolam (Xanax) calm brain activity, and researchers have asked whether they blunt the effect of TMS. The findings are mixed:
- In a US study of 181 patients, response at six weeks was 16.4% among benzodiazepine users versus 35.5% among non-users. The authors cautioned that results were not corrected for multiple comparisons and need replication.
- In the THREE-D trial analysis, not taking a benzodiazepine was associated with the rapid-response pattern.
- A 2024 Australian study of 195 patients found no difference in response or remission between users and non-users.
So there is a signal worth discussing, but no proof that benzodiazepines stop TMS from working. If you take one regularly, your psychiatrist may talk about whether a gradual reduction makes sense for you, before or during the course. Stopping suddenly is not an option; the bupropion label, for example, treats abrupt discontinuation of benzodiazepines as a seizure-risk situation.
Stimulants: a safety check, and possibly no harm to response
If you take a prescription stimulant for ADHD, expect the team to ask about the dose. The Adderall XR label says there is some clinical evidence that stimulants may lower the convulsive threshold, mainly in people with a history of seizures or abnormal EEGs. On the other side of the ledger, the same US study above found higher response among psychostimulant users (39.2% vs 22.0%), again uncorrected and needing replication. Whether to continue it during TMS is a decision for your prescriber and the TMS team. See ADHD medication management for related care.
Ketamine, esketamine and "TMS plus a pill" protocols
Some newer protocols pair TMS with a drug given right before treatment. The single-day ONE-D protocol, for example, gives d-cycloserine and lisdexamfetamine, both off-label, before 20 sessions in one day. The Clinical TMS Society says this protocol is not FDA-cleared and its evidence does not meet the threshold to recommend it. A small placebo-controlled single-day study using d-cycloserine found no difference from placebo.
Combining TMS with ketamine is also not standard. Aetna's policy, for example, lists adjunctive ketamine with TMS as experimental. If you already receive Spravato or ketamine therapy, tell both teams so they can coordinate timing.
Supplements, cannabis and over-the-counter products
People often leave these off a medication list because they do not think of them as "real" medicines. Include them anyway. Cold and flu products, sleep aids, energy drinks and pre-workout powders can contain stimulants or sedatives, and some herbal products interact with prescription drugs. Cannabis use matters too, both for mood and because the team needs an accurate picture of anything that affects your brain. Nobody is looking to judge; the goal is a safe course and results you can interpret.
If you take supplements as part of an integrative plan, such as omega-3s, vitamin D or methylfolate, bring the bottles or a photo of the labels. Little research has looked at supplements during TMS, so the team should know what you take. For how supplements fit into broader care, see integrative mental health, nutrition and supplements.
Why a stable regimen makes results easier to read
If you start a new antidepressant in the same week you start TMS and feel better a month later, nobody can tell which one helped. That matters later, when you and your psychiatrist decide what to continue, what to taper and what to try if depression returns. For that reason, many psychiatrists prefer to hold psychiatric medications steady through the course unless there is a clear reason to change, such as troublesome side effects. Talk this through before session one so the plan is agreed.
When a medication changes mid-course
Life does not pause for six weeks. If a doctor prescribes something new, such as an antibiotic, a steroid or a sleep aid, or changes a dose:
- Tell the TMS technician or psychiatrist before your next session.
- Expect a quick safety review. The team may decide to recheck your motor threshold, which sets your dose; there is a billing code specifically for re-determining it during a course, and Aetna's policy allows extra re-mapping when the threshold may have changed.
- Also mention fever, infection or a run of bad sleep, which are on the same safety list as medications.
What to bring to your consultation
- Every prescription, with dose and timing, including "as needed" medicines such as sleep aids or anxiety pills
- Over-the-counter products and supplements
- Past antidepressants and why each stopped, which also matters for insurance; see how many medications before TMS is covered
- Alcohol, cannabis and other substance use, honestly
- Any history of seizures, head injury or fainting
Our preparing for TMS checklist covers the rest, and TMS side effects explains the seizure risk in context. Dr. Lewis's physician guide to TMS safety and seizure risk goes deeper into the numbers.
For more, return to the TMS guide or visit the TMS therapy page.
Sources
- K231926 510(k) Summary - NeuroStar Advanced Therapy System. U.S. FDA, 2024. accessdata.fda.gov
- Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biological Psychiatry, 2007. pubmed.ncbi.nlm.nih.gov
- 21 CFR 882.5805 Repetitive transcranial magnetic stimulation system. eCFR, 2026. ecfr.gov
- Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial. The Lancet, 2018. pubmed.ncbi.nlm.nih.gov
- K173620 510(k) Summary - MagVita TMS Therapy System w/Theta Burst Stimulation. U.S. FDA, 2018. accessdata.fda.gov
- A multisite, naturalistic, observational study of transcranial magnetic stimulation for patients with pharmacoresistant major depressive disorder: durability of benefit over a 1-year follow-up period. Journal of Clinical Psychiatry, 2014. pubmed.ncbi.nlm.nih.gov
- Seizures from transcranial magnetic stimulation 2012-2016: Results of a survey of active laboratories and clinics. Clinical Neurophysiology, 2019. europepmc.org
- Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. U.S. FDA, 2011. fda.gov
- Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology, 2021. europepmc.org
- Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry, 2015. pmc.ncbi.nlm.nih.gov
- Real-world effectiveness of a single-day regimen for transcranial magnetic stimulation using Optimized, Neuroplastogen-Enhanced techniques in Depression (ONE-D). Research Square (preprint), 2024. doi.org
- Clinical TMS Society's Statement on Level of Evidence for Single-Day TMS combined with Medications. Clinical TMS Society, 2025. clinicaltmssociety.org
- Single-day accelerated TMS with D-cycloserine augmentation for depression: A placebo-controlled trial. Research Square (preprint), 2025. pubmed.ncbi.nlm.nih.gov
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
- Billing and Coding: Transcranial Magnetic Stimulation (A57528). CMS Medicare Coverage Database, 2026. cms.gov
- WELLBUTRIN XL (bupropion hydrochloride) extended-release tablets - Prescribing Information. Bausch Health / DailyMed (NLM), 2026. dailymed.nlm.nih.gov
- ADDERALL XR (mixed amphetamine salts) extended-release capsules - Prescribing Information. Takeda / DailyMed (NLM), 2026. dailymed.nlm.nih.gov
- Concomitant medication use and clinical outcome of repetitive Transcranial Magnetic Stimulation (rTMS) treatment of Major Depressive Disorder. Brain and Behavior, 2019. pubmed.ncbi.nlm.nih.gov
- Trajectories of Response to Dorsolateral Prefrontal rTMS in Major Depression: A THREE-D Study. American Journal of Psychiatry, 2019. pubmed.ncbi.nlm.nih.gov
- Do benzodiazepines reduce the efficacy of transcranial magnetic stimulation?. Australasian Psychiatry, 2024. pubmed.ncbi.nlm.nih.gov
FAQs
Do I have to stop my antidepressant before TMS?
Usually not. TMS is commonly given alongside antidepressants, and some FDA clearances, such as those for adolescents, describe it as an add-on treatment. Your psychiatrist decides with you.
Can I take bupropion (Wellbutrin) during TMS?
It is decided case by case. Because bupropion's label says its seizure risk is dose-related, the team will check your dose and other risk factors and decide whether any monitoring or change is needed.
Should I stop my Xanax or Klonopin to make TMS work better?
Not on your own. Research on benzodiazepines and TMS response is mixed, and stopping suddenly can be dangerous. Ask your prescriber whether a slow, supervised taper makes sense.
Can I take ibuprofen or acetaminophen for a TMS headache?
Ask the TMS team or your prescriber which pain reliever suits you, given your other medications and health conditions. Mention any headache that is severe or does not ease.
Is it okay to drink alcohol during a TMS course?
Keep it low and steady, and tell the team about your usual drinking. Heavy drinking and alcohol withdrawal are both listed as seizure-threshold factors.
