TMS and Exercise for Post-stroke Pain

Inclusion criteria

• Male or female Veteran of US military 19 years of age
• Signed informed consent
• Minimum of 3-months since time of stroke and medically stable
• Headache has persisted for >3 months after stabilization of the stroke
• Ability to walk or tolerate recumbent cycle ergometry for 10 mins without assistance
• Stable pain medication regimen for 1 month prior to study
• Females of child-bearing potential (i.e. not postmenopausal or surgically sterile) must be using a medically acceptable method of birth control and should not be pregnant nor have plans for pregnancy or breastfeeding during the study
• Completed diagnostic, maximal graded exercise test including 12-lead ECG and indirect calorimetry (i.e. oxygen uptake, minute ventilation, respiratory exchange ratio, etc.)
• Minimum pain intensity of 30 on the Mechanical Visual Analogue Scale on average with pain symptoms.

Exclusion criteria

• Moderate to severe cognitive impairment (Montreal Cognitive Assessment score <16/30)
• Pre-stroke modified Rankin >2
• History of seizures
• Presence of any standard TMS or MRI contraindications (see human subjects)
• Current diagnosis of DSM-5-defined bipolar disorder I, schizophrenia, schizoaffective disorder, or obsessive-compulsive disorder
• Diagnosis of moderate or severe substance use disorder (except for caffeine and nicotine) during the preceding 3 months (Participants must agree to abstain from illicit drugs during the study)
• Increased risk of suicide that necessitates inpatient treatment or warrants additional therapy excluded by the protocol; and/or intensity of suicidal ideation (Type 4 or Type 5) or any suicidal behavior in the past 3 months on Columbia Suicide Severity Rating Scale (C-SSRS)
• Litigating for compensation for a psychiatric disorder

• Veterans who are in the process of applying for or receiving VA service-connected disability are eligible
• Current enrollment in another intervention trial for pain or stroke
• Persons imprisoned, of minor age, diagnosed with terminal illness, or require surrogate for consent
• Fails baseline exercise screening activities
• Persistent post-stroke headaches not better accounted for by another diagnosis
• Is unable to reliably attend intervention sessions i.e. planning to move, transportation issues
• Neurological disorder pre- or post- stroke affecting subject's ability to follow study directions