Quantitative and Repetitive TMS in ALS (QuARTS-ALS)

Inclusion Criteria: Diagnosis with ALS as per the 2020 Gold Coast Criteria; Age ≥ 18 years; Able to provide informed consent to study procedures and treatments; If taking Riluzole, must be on a stable dose for at least 12 weeks prior to Baseline; If undergoing Edaravone treatment, must be on a stable dose of at least one completed cycle (IV or Oral Edaravone) prior to Baseline; If taking AMX005, must be on stable dose for at least 4 weeks prior to Baseline; Manual muscle testing with MRC score ≥4- AND nerve conduction study CMAP amplitude ≥1.0mV in the first dorsi interosseous (FDI) on at least one side; Able to tolerate TMS procedures; Able to lie supine without BiPAP or breathing discomfort for at least 1 hour; Exclusion Criteria: Known diagnosis of dementia; Definitely or possibly pregnant (if applicable); History of allergy to Ag-AgCl electrode gel (standard neurophysiology electrodes); Any contraindications to TMS as follow: Metal implants in the head or neck (such as aneurysm clips, vessel stents), implanted medication pump, implanted brain stimulators, pacemaker, cochlear implants, or history of epilepsy. Dental fillings are permitted; Current use of an antipsychotic or antiarrhythmic medication; On medications that affect TMS measures in a PRN regimen (as needed). Continuous use of these medications on a fixed dose of 30 days prior to first Baseline Visit or after a wash-out period of 2 weeks is accepted. These medications include: benzodiazepines, muscle relaxants, tricyclic antidepressants, selective and non-selective serotonin reuptake inhibitors, hypnotics (including anti-histamine drugs) and anticholinergics drugs; History of seizure, convulsion, or epilepsy; Any contraindications to MRI such as: Large body habitus and not fitting comfortably into the scanner; Difficulty laying still for up to 1 hour in the MRI unit or significant claustrophobia; Metallic implants; Any contraindications for receiving rTMS treatment as follow: have received rTMS for any previous indication due to the potential compromise of subject blinding; have increased intracranial pressure, a space occupying brain lesion, any history of seizure except those therapeutically induced by ECT or a febrile seizure of infancy, significant head trauma with clear radiological evidence of cerebrovascular injury on imaging; have an intracranial implant or any other metal object within or near the head, excluding the mouth, that cannot be safely removed; have clinically significant laboratory abnormality, in the opinion of the one of the principal investigators or study physicians; are currently taking more than lorazepam 2 mg daily (or equivalent) or any dose of an anticonvulsant due to the potential to limit rTMS efficacy; Any other clinical condition that, in the opinion of the Site Investigator, would place the subject at increased risk or preclude the subject's full compliance with completion of the study.