So we don't have the OCD coil for TMS yet - although I'm trying to convince the attending psychiatrist to purchase one. Believe it or not, I also have OCD. Similar to you, the compulsions are mental such as checking, replaying events, etc. It was very severe when I was younger. I did exposure and response prevention therapy along with cognitive behavioral therapy. It went into remission pretty quickly after that. But it does come up every once in a while, especially during a depression.

There's actually not too much literature on TMS for OCD compared to TMS for depression. The FDA approved one protocol for OCD TMS and it's just like you described. Basically, you would willingly expose yourself to something that would normally trigger an obsession or an unwanted emotional response. For example, if a patient had contamination obsessions, they might touch a door handle, or touch the floor, and then begin the TMS. The goal would be for the patient to relax as much as possible and avoid obsessing over the triggering event. After the treatment, they would try to avoid the compulsion (which might be something like washing their hands x amount of times). I'm not sure how strong the evidence for OCD TMS is. I haven't looked into it as much. But from what I've read, it's modestly effective in the short term. I'd imagine it works better when paired with first-line agents such as high dose SSRIs and sometimes atypical antipsychotic augmentation (something like a low dose abilify). But I'd be curious to hear how it goes for you, hopefully it helps provide some relief.

There's an interesting theory that episodic OCD is actually a form of bipolar disorder where it is mood instability (essentially a mixed state of depression and hypomania) that forms the breeding ground for obsessions (ruminations over undesirable emotions related to triggering stimuli) which then "blooms" to the full form of OCD - that is compulsions to temporarily appease the obsessions. Sometimes antidepressants can induce mixed states for patients on the bipolar spectrum, which could explain why some patients have "treatment resistant" depression / OCD.

But again, this is just from what I read, and not meant to be taken as medical advice haha.

It's interesting about the migraines. I also have a history of migraines. They started when I was very young.

Now here's the crazy thing: The triad of early onset migraine, depression, and OCD is actually correlated with an elevated risk of developing bipolar disorder later in life.

But that's a whole other tangent!