Machine Learning in Guiding rTMS Treatment for GWI-Related Headaches and Body Pain

This study aims to enroll a total of 140 veterans and/or active military personnel over the 4-year study period at the VA San Diego Healthcare System (VASDHS). Participants will be randomized into receiving treatments at the left DLPFC or left DLPFC and LMC, then placed into predicted respondent or non-respondent groups. They will be assigned to 1 of 4 groups:

Group A: Predicted Respondent at Left DLPFC Group B: Predicted Non-respondent at Left DLPFC Group C: Predicted Respondent at Left DLPFC and LMC Group D: Predicted Non-respondent at Left DLPFC and LMC

Participation in this study will require 15 total visits to the VASDHS over the course of 3-4 months. The visits will be separated in the following phases:

• Pre-Treatment Assessments Phase (Weeks 1-2): Visit 1 (Screening) and Visit 2 (Baseline Assessments)
• Induction Treatment Phase (Weeks 2-4): Visits 3-12 (Weekday active rTMS sessions at >24 hours and <72 hours apart)
• Follow-Up and Maintenance Phase (Weeks 5-10): Visit 13 (1 week follow-up); Visit 14 (1 month follow-up); Visit 15 (2 months follow-up); All maintenance visits follow the final treatment of the induction phase.

Inclusion criteria

• Male or female
• Veteran or active military personnel
• Between the ages of 18 and 65 years old
• Served in the Persian Gulf region for at least 30 consecutive days between August 1, 1990, and July 31, 1991
• Meets the CDC Criteria for GWVI (GWI), with symptoms starting during or after the 1990-1991 Persian Gulf deployment. Symptoms must be present for at least 6 months prior to enrollment in the study. Symptoms must be present in at least 2 of the 3 categories of fatigue, musculoskeletal, and mood cognitive.
• Meets the Kansas Criteria for GWVI (GWI), with symptoms starting during or after the 1990-1991 Persian Gulf deployment. Symptoms must be present for at least 6 months prior to enrollment in the study. Qualifying symptoms must be at least moderate in severity and/or multiple symptoms must be present within at least 3 of 6 categories consisting of fatigue/sleep, neurological/cognitive/mood, pain, respiratory, gastroenterological, and dermatological symptomology.
• Average Overall Daily Muscle Pain Intensity ≥3 on a 0-10 NPRS, present for at least 6 months
• Average Overall Daily Extremities Joint Pain Intensity ≥3 on a 0-10 NPRS, present for at least 6 months
• Average Headache Exacerbation Intensity ≥3 on a 0-10 NPRS, with headaches occurring for at least 6 months
• Headache Exacerbation/attack ≥ 1 time per week with the average intensity ≥3 on a 0-10 NPS, lasting > 1 hour in the past three months
• International Headache Society Criteria for Migraine Headache without aura

Exclusion criteria

• Children under the age of 18
• Pregnant women
• Individuals with cognitive/decisional impairment
• Non-English speaking individuals
• Prisoners of War
• Incarcerated individuals
• VA employees - including VA paid, IPA, or WOC
• Students of the institution or of the investigator
• Patients with cancer
• History of pacemaker implant
• Presence of ferromagnetic material (e.g., bullet fragment, shrapnel, device implant) in the brain or body that will prohibit the patients from having a brain MRI
• History of dementia, major psychiatric diseases, or life-threatening diseases
• Presence of any other chronic neuropathic pain states such as Complex Regional Pain Syndrome or Painful Peripheral Neuropathy
• Known diagnosis of moderate to severe osteoarthritis and/or rheumatologic joint pain prior to the GWI deployment
• Low back pain with mechanical origins such as lumbar radiculopathy or radiculitis or lumbar facet arthropathy
• Concurrent conditions, like lupus, that can produce symptoms compatible with GWVI
• History of seizure
• Pending litigation
• History of Traumatic Brain Injury-related headaches
• Chronic Tension or Cluster Headache. However, subjects with occasional tension headaches (less than once every three months and lasting no more than 24 hours) will not be excluded from the study.
• Ongoing Cognitive Rehabilitation or Treatment of PTSD
• Recent exacerbation of anxiety disorder symptoms, active substance dependence, and/or current psychotic symptoms
• Ongoing suicidal/homicidal ideation or recent (in the past 6 months) suicidal attempts
• Patients who receive any narcotic-based analgesic, topical analgesics over the affected site, steroid and local anesthetic injection, anticonvulsants, and antipsychotic medications less than 7 days prior to the pretreatment assessment
• Patients who do not agree to avoid use of non-pharmacologic treatments, including but not limited to, transcutaneous electrical nerve stimulation unit (TENS), acupuncture, acupressure, and therapeutic massage during the entire study.
• Patients who do not agree to use additional acetaminophen (up to a maximum total of 3g per day) as the only rescue medication
• Patients who have received rTMS within the past 6 months