Quantitative and Repetitive TMS in ALS - Recruiting for Stage 2

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; * Patients are allowed to start or continue the standard of care treatments for ALS. Presently these include oral riluzole, and oral or intravenous edaravone; * Able to lie supine without BiPAP or breathing discomfort for at least 1 hour; * No 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 medications or medical conditions that, at the discretion of the Principal Investigator, could potentially increase the risk of seizures or interfere with stage outcomes; * 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, but are not limited to: 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; Exclusion Criteria: * Known diagnosis of dementia; * Definitely or possibly pregnant (if applicable); * History of allergy to Ag-AgCl electrode gel (standard neurophysiology electrodes); * Unable to tolerate TMS procedures; * Lack of MRI brain performed prior to the stage, inability to perform an MRI at baseline due to orthopnea, or: * 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 stage.