Repetitive transcranial magnetic stimulation (rTMS) for the treatment of epilepsy: a systematic review and meta-analysis of clinical trials (from 1990 to 2025).

OBJECTIVES: This systematic review and meta-analysis evaluates the efficacy of repetitive transcranial magnetic stimulation (rTMS) in reducing seizure frequency in patients with epilepsy, synthesising evidence from randomised controlled trials (RCTs). DESIGN: Systematic review and meta-analysis of RCTs conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020 guidelines. SETTING: Literature search across international (PubMed, EMBASE, Cochrane, Scopus, ScienceDirect, Google Scholar) and Iranian (SID, Magiran, IranMedex) databases. PARTICIPANTS: Adult patients diagnosed with epilepsy, including those with drug-resistant focal epilepsy, from 14 included RCTs (total n=516). INTERVENTIONS: Active low-frequency rTMS (0.3-1 Hz) compared with sham stimulation or active control (eg, antiepileptic drug therapy). MAIN OUTCOME MEASURES: The primary outcome was the mean change in weekly seizure frequency analysed using standardised mean difference (SMD). RESULTS: From 1952 retrieved records, 14 RCTs were reviewed and 8 were meta-analysed (n=367). The pooled analysis showed a statistically significant reduction in seizure frequency favouring rTMS (SMD=-0.46, 95% CI -0.57 to -0.34, p=0.001, Z=-7.67), with low heterogeneity (I²=0.1%). The combined mean seizures were 6.1 (intervention) versus 7.4 (control) per week. No significant publication bias was detected (Egger's test p=0.086). CONCLUSIONS: Low-frequency rTMS demonstrates a significant short-term reduction in seizure frequency. However, the clinical durability of this effect remains uncertain due to limited follow-up in existing trials. Definitive conclusions require larger, standardised RCTs with longer-term outcomes. TRIAL REGISTRATION: No human participants included.