Purpose of Review <p>Insomnia, characterized by difficulty falling asleep, staying asleep, or early awakening, affects a significant portion of the population. Refractory insomnia, which lasts more than three months and is unresponsive to pharmacological interventions, presents a therapeutic challenge due to drug resistance and dependence. Our study explored the potential mechanisms of repetitive transcranial magnetic stimulation (rTMS) as a treatment for refractory insomnia.</p> Recent Findings <p>Recent studies highlight the efficacy of rTMS in managing refractory insomnia, showing significant improvements in sleep quality with minimal side effects. Theta burst stimulation (TBS), a variant of rTMS, has been shown to be effective in treating depression and improving sleep outcomes, suggesting its potential in refractory insomnia. rTMS targeting the left dorsolateral prefrontal cortex (DLPFC) increases sleep spindle density and slow-wave activity, improving thalamocortical synchronization and sleep quality. The mechanisms by which rTMS alleviates depressive symptoms may also provide insights into the treatment of refractory insomnia. Additionally, rTMS has been associated with elevated brain-derived neurotrophic factor (BDNF) levels and improved functional connectivity, which are correlated with better sleep quality. Structural changes, such as increased gray matter volume in the bilateral thalamus, further underscore the role of rTMS in sleep regulation.</p> Summary <p>Our study synthesizes the literature on the neurophysiological, neurochemical, and neural network effects of rTMS in treating refractory insomnia, providing a comprehensive understanding of rTMS as a potential therapeutic intervention.</p>