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High Frequency (HF) rTMS protocols have been shown to be more effective in inducing cortical excitability when using monophasic pulses of Positive Anode current direction. Biphasic pulses also showed lower efficiency, and even reversing monophasic pulse direction induced paradox inhibition of cortical excitability.

A somewhat different picture evolves when evaluating the impact of induced current direction and pulse shape on the outcome of rTMS. HF protocols have been shown to induce stronger facilitation of cortical activity with monophasic pulses of PA direction while biphasic pulses had a lower efficiency. Reversing the induced current direction of monophasic pulses even induced a paradox inhibition of cortical excitability (for review see Huang et al., 2009).