O u t p a t i e n t    E l e c t r i c    S t i m u l a t i o n

In addition to Magnetic (rTMS), there are other brain stimulation options: 

1   tACS (including CES) = transcranial Alternating Current Stimulation

(or Cranial Electrotherapy Stimulation) 

2   tDCS = transcranial Direct Current Stimulation 

3   tTNS = transcutaneous Trigeminal Nerve Stimulation 

4  tVNS = Transcutaneous Vagus Nerve Stimulation

5  Light = Light Therapy Stimulation

6  TENS = Transcutaneous Electric Nerve Stimulation


These are not like "shock" therapy (ECT). and there are 3 differences (advantages) vs ECT:

1) ECT uses 450 volts at 1 amp current, these use about .002 amps (2 milliamps) (500 times less current)

2) no anesthesia is needed, patients are awake and drive to and from appointments

3) These Improve Memory (ECT can impair memory)

1) transcranial Alternating Current Stimulation (tACS)

including Cranial Electrotherapy Stimulation (CES)

Is a method of brain stimulation which has been used since the 1950s, and was FDA approved for Depression, Anxiety, Pain & Insomnia in the Early 1970s.*

*Class III for the indication of “insomnia, depression, and anxiety” through a “pre-amendment” regulatory pathway (510[k]), which required only demonstration of substantial equivalence to legally marketed devices predating FDA regulation)Class III for the indication of “insomnia, depression, and anxiety” through a “pre-amendment” regulatory pathway (510[k]), which required only demonstration of substantial equivalence to legally marketed devices predating FDA regulation)

Pictured above are Fisher-Wallace $699 (on the left) and CES-Ultra $349 (on the right), click on them to go to the companies webSites. There is also a device called Alpha-Stim, which is about $1200, we have not used the Alpha-Stim unit, but have been told by reliable sources that effectiveness has not been seen with it. Other devices cost as much as $8,000. No clear advantages have been demonstrated with the expensive devices. I have seen beneficial effects from the two above devices and another physician that I know said that about 70% of patients get significant benefit (50-100% reduction of symptoms).

2) transcranial Direct Current Stimulation (tDCS)     is not cleared in the US but in the European Union is approved for Fibromyalgia and Migraine also...

1) it is widely used  by video gamers and others who seek to optimize brain function (& Their KDR) for more info click here

2) is being investigated by the military to reduce learning time in training for more info click here or here

3) has a large amount of scientific investigation and interest (> 6,000 articles on MedLine) to see all, click here

4) has been studied for mood disorders, schizophrenia, OCD, stroke, head trauma, and weight loss. It is too soon to know whether it is effective.

5) can be done with inexpensive devices purchased on the internet ($39 - $150) or more expensive devices designed for iontophoresis ($400-1200) (eg ActivaDose or Chattanooga)

6) the exact placement location of the electrodes (montage) is very important for what part of the brain is stimulated or inhibited


tdcs web2.png
Devices designed and approved for iontophoresis can be safely used for tDCS

Devices designed and approved for iontophoresis can be safely used for tDCS

Click on the picture above to read the outstanding New Yorker article "Electrified" Adventures in transcranial direct-current stimulation. BY ELIF BATUMAN



Of the many articles on tDCS, more than 1,000 scientific publications describe applications of tDCS for these and other uses:

Auditory Hallucinations (Koops 2015)

Autism (D'Urso 2015)

Cerebral Palsy (Duarte Nde 2014, D'Urso 2014, Grecco 2013)

Cognitive Enhancement (Kantak 2015, Parasuraman 2014, Bennabi 2014, Martin 2014, Lally 2013)

Dementia (Elder 2015, Meinzer 2015, Sandrini 2014, Mahdavi 2014, Hansen 2014, Khedr 2014, Babiloni 2014, Boggio 2009)

Depression (Brunoni 2015, Shiozawa 2015, Palm 2015, Gálvez 2015, Dell'Osso 2014, Vigod 2014, Ho 2014, Player 2014, Dell'Osso 2014, Brunoni 2014, Valiengo 2013, Alonzo 2013, Martin 2013, Berlim 2013, Blumberger 2012, Loo 2012, Murphy 2009)

Eating Disorders (Widdows 2014)

Fibromyalgia (Fagerlund 2015, Marlow 2013, Valle 2009, Fregni 2006)

Functional Neurological Disorders (McWhirter 2015)

Generalized Anxiety Disorder (GAD) (Shiozawa 2014)

Migraine (DaSilva 2015) 

MS Fatigue (Ferrucci 2014)

Obsessive-Compulsive Disorder (Senço 2015, Narayanaswamy 2015)

Pain (Concerto 2015, O'Neill 2015, O'Connell 2015, Boldt 2014, Boldt 2014, O'Connell 2014, Fagerlund 2013, Moreno-Duarte 2014, Nizard 2012, Luedtke 2012, O'Connell 2012)

Chronic Low Back Pain (Luedtke 2015)

Myofascial Pain Syndrome (Choi 2014)

Neuropathic Pain (Mehta 2015, Razumov 2015, Nardone 2013)

Parkinson’s (Li 2015, Gajo 2015, Manenti 2014, Doruk 2014, Benninger 2010)

PTSD (Marin 2014, Wu 2008)

Schizophrenia (Mondino 2015, Praharaj 2015, Nieuwdorp 2015, Shenoy 2015, Shivakumar 2015, Jacks 2014, Miyamoto 2014, Jacks 2014, Hoy 2014, Andrade 2013, Nawani 2013, Brunelin 2013)

Stroke (Mortensen 2015, Gall 2015, Claflin 2015, Ang 2015, Marchina 2015, Pollock 2014, Gillick 2014, Di Pino 2014, Lüdemann-Podubecká 2014, Plow2014, Pollock 2014, Tahtis 2014, Plow 2013, Bradnam 2013, Dmochowski 2013, Ang 2012, Edwardson 2013, Kandel 2012, Takeuchi 2012, Butler 2013, Kim 2009)

Post Stroke Aphasia (Galletta 2015, Elsner 2015, Thiel, Khedr 2014, Manenti, 2015, Lee 2013, Elsner 2013)

Tinnitus (Pal 2015, Shekhawat 2015, Shekhawat 2014, Shekhawat 2015, Joos 2014, Vanneste 2014, Lee 2014, Elsner 2013, Shekhawat 2013, De Ridder 2012, Langguth 2012, Plewnia 2011, Vanneste 2010)

TMJ (Oliveira 2015)

Traumatic Brain Injury (Shin 2014, Leśniak 2014)

Sleep & Fatigue (post-polio syndrome) (Acler 2013)


unlike the tACS, there is no frequency, pulse width, pulse shape to adjust but there are different ways to position the electrodes (montages)

By positioning the electrodes differently, one can individualize the effect you want.

There are many sources to learn about different montages, the pictures above are from tDCSPlacements.com    click on the pictures or below to go there

If you want to buy a tDCS unit to use at home you can do it. I neither encourage nor discourage this. In general it is safe. There are many devices to choose from. The Soterix and NeuroConn are in the $3,000-$10,000 range and are probably good devices but there is no evidence that they are safer or more effective.  ActivaDose is probably the best value ($350) it is a medical grade device and FDA cleared in the US for another purpose. They have high quality standards. The Chattanooga was smaller, more portable and had two outputs instead of one, but it is no longer available and was not as user friendly. If you look on Amazon or EBay you will find $20-$100 devices that are not good. But there is a well engineered tDCS device called "PriorMind" ($150) by a brilliant young engineer in Hong Kong named Tam Zombie (ta_zombi). It works extremely well and has circuitry which keeps the current constant even if the impedance varies. It turns on at 0.5mA and can be increased to 2.0mA. It does not turn off automatically so caution is needed to turn it off. www.foc.us is the most obvious and best choice for most people. They have complete systems for $99 that have everything you need. Having purchased and used almost every device on the market, I am most impressed with Foc.us. I order their products no matter what, because I have never been disappointed with them. But in the office I used the ActivaDose device for legal reasons because it has a legal status (FDA cleared for iontophoresis) whereas the Foc.us is technically a recreational device. 

3) Trigeminal Nerve Stimulation (tTNS)

is FDA cleared for the treatment of migraine and cluster headaches. It is also being investigated for seizure prevention.

Although the manufacturer states that daily treatment is required for results, we have found that many people experience relief from the first treatment. Instead of giving a prescription and having patients buy a device ($400), wait three weeks to get it and not know if it will work, we do the stimulation in the office. If successful, we can loan a device until the purchased one arrives.

Trigeminal Nerve Stimulation is also being actively investigated for other disorders including:

Seizures (Cook 2015, Soss 2015, Moseley 2014, Zare 2014, Pack 2013, DeGiorgio 2013, DeGiorgio 2009, DeGiorgio 2006, DeGiorgio 2003, Fanselow 2012, Pop 2011), 

Depression (Shiozawa 2015, Cook 2013, Schrader 2011), 

ADHD (McGough 2015), 

Fibromyalgia (Shiozawa 2014), 

PTSD (Trevizol 2015), 

Generalized Anxiety Disorder (Trevizol 2015), 

(in addition to Trigeminal Nerve Stimulation for headache, Transcutaneous Occipital Nerve Stimulation may also offer a way to help provide relief and reduce suffering.)

4) transcutaneous Vagus Nerve Stimulation (tVNS)

is a very new and exciting treatment for medical and psychiatric conditions.

In 1997 the FDA approved the surgical implantation of a vagus nerve stimulator for the treatment of Seizures (epilepsy). Then for depression in 2005 and for weight loss in 2015.  (Information about surgical vagus nerve stimulation is below. We do a non-surgical method but much can be learned from the older procedure.)

Because a small specific area of skin on the outer ear is innervated by the vagus nerve, gentle stimulation of that skin has been found to produce similar brain activation (Kraus 2007, Dietrich 2008) as the surgical implant.

In Europe two tVNS devices have been approved for use -  for Epilepsy (seizures) in 2010 and Pain in 2012 (CerboMed-Nemos) and another device for headaches (GammaCore) .

GammaCore is also approved for the acute and prophylactic treatment of primary headaches (cluster headache, migraine, hemicrania continua), and reactive airway disease (asthma, exercise- induced bronchospasm, COPD), as well as adjunctive therapy for epilepsy prevention and reducing the symptoms of certain anxiety/depression conditions (eg, panic disorder, posttraumatic stress disorder, major depressive disorder, obsessive- compulsive disorder), gastric mobility disorders, and irritable bowel syndrome

(Grazzi L, Usai S, Bussone G.. Gammacore device for treatment of migraine attack: 2014:G12.

Gaul C, Diener H, Solbach K, et al.. Non-invasive vagus nerve stimulation using gammacoreVR for prevention and acute treatment of chronic cluster headache: Report from the randomized phase of the preva study; 2014:I7. )

OTHER  USES  of Transcutaneous Vagus Nerve Stimulation (tVNS):

Although the transcutaneous method has not been not been specifically approved in the United States (i.e. off-label) it is legal and being investigated (and found to be effective and safe) for many conditions including:

Atrial Fibrillation (Stavrakis 2015, Yu 2013)

Depression (Hein 2013, Aaronson 2013)

Dementia (Polak 2006)

Diabetes (Huang 2014, Li 2015)

Endotoxemia (Huston 2007, Schmidt 2008)

Memory (Jacobs 2014 2015)

Myocardial Infarction (Wang 2015)


Chronic Migraine Headache (Straube 2015)

Acute Migraine (Goadsby 2014)

Cluster Headache (Gaul 2014, Nesbitt 2013)

Pain (Laqua 2014, Busch 2013)

Postoperative Cognitive Dysfunction (POCD) (Xiong 2009)

Chronic Pelvic Pain (Napadow 2012)

Tinnitus (Li 2015, Hyvarinen 2015, Kreuzer 2014, Kreuzer 2015)

Schizophrenia (Hasan 2015)

Stroke (Cai 2014)

In our experience, it is most effective for Anxiety (Generalized Anxiety, Panic Disorder, PTSD and Social Anxiety) and Insomnia.



How transcutaneous Vagus Nerve Stimulation Works (Mechanism of Action)

1) stimulating the skin of the ear, 

2) stimulates the Auricular Branch of the Vagus Nerve

3) the stimulation goes to a nucleus (cluster of nerve cells) called the Nucleus tractus solitarius

4) the Nucleus tractus solitarius receives information from the body (heart, lungs, intestines, immune system) and

5) sends output to several structures including the Locus coeruleus and indirectly the Dorsal raphe nucleus.

6) Locus Ceruleus is the brain's primary source of norepinephrine (aka noradrenaline) 

7) Dorsal Raphe nucleus is the  brain's primary source of serotonin

8) so those two structures influence alertness/energy (noradrenaline) and confidence (serotonin)

9) those two then send those chemicals (neurotransmitters) to newer parts of the brain, especially parts for thinking and feeling, so there is more calm and less stress

10) those two then send those chemicals (neurotransmitters) to the whole brain, especially parts for thinking and feeling sends Serotonin (Calm Confidence) & Norepinephrine (Relaxed Energy) - more to the thinking intentional Prefrontal Cortex, and less to the Amygdala (Hippocampus and Anterior Thalamus). This reduces anxiety and panic (fight or flight response).


• How Does tVNS Work?


Fig. 6: The vagus nerve sends afferents to the nucleus tractus solitarius (NTS), which in turn projects to the locus coeruleus through disynaptic pathways... Vagus nerve stimulation (VNS) would facilitate the excitatory pathway on neurons in the locus coeruleus more than the inhibitory one. The locus coeruleus would then modify the firing rate of serotonin (5-HT) neurons through its monosynaptic input to the dorsal raphe nucleus. Therefore, VNS is believed to change the locus coeruleus, and then indirectly the 5-HT neurons in the dorsal raphe nucleus. It leads to a marked enhancement of norepinephrine (NE) and serotonin (5-HT) transmission. (from Manta 2009 Enhancement of the Function of rat serotonin and norepinephrine neurons by sustained vagus nerve stimulation)

••How Does tVNS Work?

2) BETTER RELATIONSHIP WITH SELF & LESS RUMINATION- Transcutaneous vagus nerve stimulation increases the functional connectivity (the way parts of the brain connect and communicate) of the default mode network (DMN) structures. The DMN is a set of brain areas that are more active when you are not focused on outside things or activities, awake and at rest. The DMN is related to our relationship with ourself, our thoughts about our feelings, and emotion control (Connolly 2013, Berman 2011 & Nejad 2013). People who are depressed have more self-focus and sensitivity to stress (Rodriguez 2012). Part of the DMN (medial) is activated during focus on self and part (Lateral) focus on others. tVNS shifts the focus (Fang 2015) "The Functional Connectivity between the DMN and anterior insula and parahippocampus decreased; the FC between the DMN and precuneus and orbital prefrontal cortex increased" (see below).

3) LESS STRESS MORE RELAXATION - Transcutaneous vagus nerve stimulation improves heart rate variability (Clancy 2014, Leeds, UK), Lower sympathetic (adrenalin, fight or flight), and more parasympathetic (rest, digest, attend and befriend) activity is a predictor of better health in many conditions including heart disease, high blood pressure, sleep apnea and obesity.


The story of modern vagus nerve stimulation, began with Jacob Zabara at the Department of Physiology, Temple University School of Medicine in Philadelphia. He developed and refined the process of surgical vagus nerve stimulation for epilepsy (seizures). The surgically implanted device was FDA approved for seizures in 1997 and depression in 2005. The procedure that we use is not surgical, yet the brain structures which are activated reflect vagus nerve activity.

Transcutaneous vagus nerve stimulation has advantages over surgery

1) Less pain,

2) Less cost

3) More people can benefit from it and

4) More flexible, more possibilities to change the procedure to suit individual people, left, right, front back, low frequency high frequency etc.

5) People with depression get better in one month instead of one year.  

Figure 3. Yellow indicates brain regions that showed significant functional connectivity increase with default mode network in the transcutaneous vagus nerve stimulation group as compared with sham transcutaneous vagus nerve stimulation. Blue indicates brain regions whose default mode network functional connectivity changes (posttreatment minus pretreatment) were negatively correlated with the corresponding Hamilton Depression Rating Scale score changes across all subjects. L, left; OPFC, orbital prefrontal cortex; Precu, precuneus; rACC, rostral anterior cingulate cortex. (Fang 2016 transcutaneous vagus nerve stimulation Modulates Default Mode Network in Major Depressive Disorder. )





(FIGURE 5–1. from Higgins & George 2009 - Brain Stimulation Therapies for Clinicians)

Vagus Nerve Stimulation began as a Surgical Procedure

The Cyberonics Surgically Implanted Vagus Nerve Stimulator,  FDA Cleared in 1997.  

The VNS generator (A) contains a small battery that generates electrical impulses. A surgeon implants the device under the skin over the chest (B) and attaches the electrodes to the left vagus nerve (C). Regular sig- nals from the VNS device travel up the vagus nerve (D) and ultimately alter activity in the cerebral cortex. 

(FIGURE 5–3. from Higgins & George 2009 - Brain Stimulation Therapies for Clinicians)

Information from the Body rises to update the Brain. This informs the part of the brain that regulates Arousal and Emotion. 

The sensory fibers of the vagus nerve terminate in the nucleus tractus solitarius (NTS), and the major output of the NTS is to the locus coeruleus (and several other structures such as the raphe nuclei). Projectors from the locus coeruleus to other areas of the brain are believed to mediate some of the effects of VNS. (FIGURE 5–5. from Higgins & George 2009 - Brain Stimulation Therapies for Clinicians) 

Does Vagus Nerve Stimulation Work For Medical Conditions Also?

Surgical Vagus Nerve Stimulation for Epilepsy (Cyberonics) was FDA cleared in 1997. Since then, much has been learned.

Kevin Tracey, MD, a surgeon and scientist in Long Island, New York has used this surgically implanted neuro-pacemaker for other conditions beyond epilepsy, and investigated the remarkable health benefits of vagal nerve stimulation. In 2003 he and colleagues published the landmark paper "The Cholinergic Anti-inflammatory Pathway: A Missing Link in Neuroimmunomodulation" In March of 2015, Scientific American devoted an entire special issue to this topic, with superb illustrations and text in plain language. Most of what he discusses also applies to tVNS but without the cost and complications of surgery.

Light - Light Therapy Stimulation

Light therapy has long been used sucessfully for treatment of seasonal affective disorder (Winter Blues). Major depression and PMD also respond well. Large boxes with special frequencies have been used

Light therapy boxes can be found for $50-150 on EBay or Amazon

New wearable light therapy devices are available.