In this study, we will use repetitive transcranial magnetic stimulation (rTMS) at 1.0 Hz to treat patients with poorly controlled neocortical epilepsy refractory to pharmacological treatments as a continuation of our previous study (1.0 Hz TMS in 24 patients with refractory partial epilepsy). Previously, we observed that 1.0 Hz rTMS reduced seizure frequency during the first 2 weeks after TMS, although the difference did not reach statistical significance. However, the results suggested that patients with neocortical temporal foci would have a better response than those with mesial temporal foci. We wish to see whether rTMS leads to a significant reduction in seizure frequency in neocortical epilepsy considering the depth of magnetic field. The design will include two parallel groups, one receiving active treatment, and one sham stimulation directed away from the epileptic focus. The patients and the rating physicians will be blinded to the treatment. 1.0 Hz TMS is a rate proven to induce long term depression in animal models and reported to decrease the excitability of both human and animal cerebral cortex. Our preliminary controlled study showed a trend for reduced seizure frequency after 1.0 Hz stimulation. The main outcome measure will be a reduction in seizure frequency over two weeks after stimulation.
INCLUSION CRITERIA: Patients will be selected from the ERB, NINDS, NIH Epilepsy Clinic. Age 5 to 65 at entry to protocol. History of localization-related epilepsy for two or more years. Patients are on a stable anti-convulsant regimen defined as unchanged medicines and dose modifications lower than 20% in the last month. Blood levels of anticonvulsants will be measured at the beginning of the study, prior to stimulation and after the study to assure that the type and dose of medication will remain constant. Seizures are not completely responsive to medical treatment (1 or more seizures per week for at least 6 months) and patients have continued seizures despite best medical treatment in the past. The patients have a localized neocortical seizure focus, based on EEG and neuroimaging findings. EXCLUSION CRITERIA: Patients will be excluded from this study if they: 1. are pregnant women (tested with urine pregnancy test). The effects of rTMS on pregnancy are unknown. 2. have severe coronary disease. 3. have increased intracranial pressure as expressed by the presence of papilledema. 4. have cardiac pacemakers. 5. take neuroleptic or antidepressant medications. 6. progressive neurologic disease.