C. Hain, MD.•
Hearing Page • Page last modified:
May 25, 2022
Musical hallucinations constitute a complex type of auditory hallucination characterized by perception of melodies, music, or song. (Alvaraez Perez et al, 2017). According to Teunisse and Rikkert, 3.6% of 194 patients referred for testing had MH. This seems a very high figure to us, as in our experience, most patients are reluctant to endorse MH out of a fear of being labeled as having a psychiatric disorder. This was also the observation of Aziz (2009).
Warner and Aziz (2005) reported that in the Wales, the most popular tune was "Abide with Me".
Cause of MH.
As a general themes, MH are reported in patients with poor hearing, with psychiatric disorders, and in patients with parkinsonism (perhaps with too much dopamine).
Musical hallucinations are encountered in severe hearing disorders, psychiatric disorders as well as organic brain disorders. Golden and Josephs (2015) reported on 393 subjects. Their discussion was as follows:
"The mean age at onset of the hallucinations was 56 years, ranging from 18 to 98 years, and 65.4% of the subjects were female. Neurological disease and focal brain lesions were found in 25% and 9% of the total subjects, respectively. Sixty-five subjects were identified with a neurodegenerative disorder, with the Lewy body disorders being the most common. Visual hallucinations were more common in the group with neurological disease compared to the psychiatric, structural, and not otherwise classifiable groups (P < 0.001), whereas auditory hallucinations were more common in the psychiatric group compared to all other groups (P < 0.001).
Structural lesions associated with musical hallucinations involved both hemispheres with a preference towards the left, and all but two included the temporal lobe. Hearing impairment was common, particularly in the not otherwise classifiable category where 67.2% had documented hearing impairment, more than in any other group (P < 0.001). Those with an underlying neurodegenerative disorder or isolated hearing impairment tended to hear more persistent music, which was often religious and patriotic compared to those with a structural lesion, where more modern music was heard, and those with psychiatric disorders where music was mood-congruent. This case series shows that musical hallucinations can occur in association with a wide variety of conditions, of which neurological disease and brain lesions represent a substantial proportion, and that Lewy body disorders are the most commonly associated neurodegenerative diseases."
The core idea here is that hallucinations are due to a disconnection syndrome -- when the brain has no input from the ears, it may create something to fill in the loss. This is sometimes called the "auditory Charles Bonnet syndrome". (Colon-Rivera and Oldham, 2014). Niranjan et al (2017) reported a case of a patient with severe hearing loss.
Of course, auditory hallucinations are a feature of schizophrenia. This mainly involves hearing voices. However, schizophrenia is not commonly reported in MH.
According to Rocha et al (2015), Psychiatric assessment showed that 68.75% of cases had depression, 6.25% had anxiety disorder and 25% had no psychiatric conditions.
According to Bergman et al (2014), "MHs represent a complex psychopathological phenomenon, hallucinatory in content and obsessive-compulsive (OC) in form, justifying trial with an anti obsessive agent." Bergman reported success with escitalopram (an SSRI).
Bleich-Cohen et al (2011) reported a single patient with schizophrenia and OC, and proposed that this was an "obsessive musical hallucination".
Our take on this is that for the most part, medications don't cause auditory hallucinations, unless they induce psychiatric disorders.
- MH have been reported in pramipexole ( a dopamine agonist) by Katola and Ueno, 2014. This is somewhat reasonable.
- Tomar and Cheung reported MH attributed to dipyrimadole. This is hard to follow -- that a medication to prevent blood clots should cause musical hallucinations..
Concerning brain disorders
For the most part, MH are reported in patients with damage to the auditory cortex, as well as damage in the central auditory pathways.
- Kobayashi (2018) reported a case of MH in a case of brain trauma where there were contusions to both temporal lobes.
- Golden and Josephs (2015) suggested that MH were commonly found in neurological disorders, and in particular Lewy Body disorders.
- Woo et al (2014) reported a single case of a infarct in the thalamocortical radiations.
- Some patients may have MH as a result of mild seizure disorders. (This is not a "fugue state")
- Serby et al (2013) suggested that MH might result from pontine lacunar lesions. This is difficult to understand. One would expect that perhaps there might be an issue with an infarct in the trapezoid body, which is where information from each ear decussates. Infarcts in the midline pons where the trapezoid body is located are very uncommon. .
- Mittal and Giron (2010) reported MH in one their patients with Parkinsonism. Perhaps these were patients with DLB, or perhaps patients with too much dopamine.
- Gondim Fde et al (2010) reported a single patient with PD thought to have them induced by amantadine (a dopamine agonist)
- Isolan et al (2010) reported MH in one patient with a right insular glioma.
- Williams et al (2008) reported MH after temporal lobectomy.
- The author of this page has encountered a case of a man with bilateral temporal lobe strokes, with MH.
- The author of this page has encountered a patient who had a midbrain contusion resulting in complete deafness, that was replaced by musical hallucinations as hearing was gradually restored.
Auditory hallucinations are sometimes encountered in patients with no obvious cause. (e.g. Brunner and Amedee, 2015; Peritogiannis et al, 2016; Zabalza-Estevez, 2014).
As a general comment, MH associated with poor hearing are treated with hearing aids. Those with psychiatric disorders, generally with antipsychotic drugs, which are often dopamine blockers.
Coeberg et al (2015) reported on treatment attempts.
"A literature search yielded 175 articles discussing a total number of 516 cases, of which 147 articles discussed treatment in 276 individuals. We analyzed the treatment results in relation to the etiological factor considered responsible for the mediation of the musical hallucinations, i.e., idiopathic/hypoacusis, psychiatric disorder, brain lesion, and other pathology, epilepsy or intoxication/pharmacology. RESULTS: Musical hallucinations can disappear without intervention. When hallucinations are bearable, patients can be reassured without any other treatment. However, in other patients musical hallucinations are so disturbing that treatment is indicated. Distinct etiological groups appear to respond differently to treatment.
In the hypoacusis group, treating the hearing impairment can yield significant improvement and coping strategies (e.g., more acoustic stimulation) are frequently helpful. Pharmacological treatment methods can also be successful, with antidepressants being possibly more helpful than antiepileptics (which are still better than antipsychotics). The limited use of acetylcholinesterase inhibitors has looked promising.
Musical hallucinations occurring as part of a psychiatric disorder tend to respond well to psychopharmacological treatments targeting the underlying disorder. Musical hallucinations experienced in the context of brain injuries and epilepsy tend to respond well to antiepileptics, but their natural course is often benign, irrespective of any pharmacological treatment. When intoxication/pharmacology is the main etiological factor, it is important to stop or switch the causative substance or medication."
- Peritogiannis et al (2016) reported treatment with atypical antipsychotics in a patient with no psychiatric illness.
- Blom et al (2015) reported treatment with anticholinesterase inhibitors. Also Zilles et al (2012). It is difficult to see a rationale for doing this.
- Aizawa et al (2014) reported a single case that responded to carbamazepine (a seizure medication).
- Huntly et al (2011) also reported a single case of response to lamotrigine (another seizure medication).
References for Musical Hallucinations:
- Aizawa, S., et al. (2014). "Musical hallucinations responding to a further increase of carbamazepine." BMJ Case Rep 2014.
- Alvarez Perez, P., et al. (2017). ""Doctor, I Hear Music": A Brief Review About Musical Hallucinations." Open Neurol J 11: 11-14.
- Aziz, V. (2009). "Musical hallucinations in normal children and adult non-psychiatric population." BMJ Case Rep 2009.
- Bergman, J., et al. (2014). "The beneficial effect of escitalopram on obsessive-compulsive-related musical hallucinations in elderly patients with hearing impairment: a case series." Int Clin Psychopharmacol 29(5): 263-265.
- Blom, J. D., et al. (2015). "Musical hallucinations treated with acetylcholinesterase inhibitors." Front Psychiatry 6: 46.
- Brunner, J. P. and R. G. Amedee (2015). "Musical hallucinations in a patient with presbycusis: a case report." Ochsner J 15(1): 89-91.
- Colon-Rivera, H. A. and M. A. Oldham (2014). "The mind with a radio of its own: a case report and review of the literature on the treatment of musical hallucinations." Gen Hosp Psychiatry 36(2): 220-224.
- Coebergh, J. A., et al. (2015). "Musical hallucinations: review of treatment effects." Front Psychol 6: 814.
- Golden, E. C. and K. A. Josephs (2015). "Minds on replay: musical hallucinations and their relationship to neurological disease." Brain 138(Pt 12): 3793-3802.
- Gondim Fde, A., et al. (2010). "Transient amantadine-induced musical hallucinations in a patient with Parkinson's disease." Mov Disord 25(10): 1505-1506.
- Hermesh, H., et al. (2004). "Musical hallucinations: prevalence in psychotic and nonpsychotic outpatients." J Clin Psychiatry 65(2): 191-197.
- Huntley, J. D., et al. (2011). ""In the midnight hour": a case report of musical hallucinations with multiple etiological factors treated with lamotrigine." Int Psychogeriatr 23(2): 322-324.
- Isolan, G. R., et al. (2010). "Musical hallucinations following insular glioma resection." Neurosurg Focus 28(2): E9.
- Kataoka, H. and S. Ueno (2014). "Auditory musical hallucinations associated with extended-release pramipexole in an elderly patient with Parkinson's disease." Medicine (Baltimore) 93(27): e251.
- Kobayashi, Y. (2018). "A Case of Traumatic Brain Injury Presenting with Musical Hallucinations." Case Rep Neurol 10(1): 7-11.
- Mittal, M. and L. T. Giron, Jr. (2010). "Elvis is back: musical hallucinations in a Parkinson disease patient." South Med J 103(8): 837-841.
- Niranjan, V., et al. (2017). ""Musical Ear Syndrome"-Musical hallucinations in a patient with severe hearing loss-A report." Asian J Psychiatr 29: 101-102.
- Peritogiannis, V., et al. (2016). "Atypical antipsychotics for the treatment of musical hallucinations in an elderly patient without a psychiatric disorder." J Neurosci Rural Pract 7(4): 606-608.
- Rocha, S. C., et al. (2015). "Multidisciplinary assessment of patients with musical hallucinations, tinnitus and hearing loss." Psychopathology 48(4): 251-255.
- Serby, M. J., et al. (2013). "Musical hallucinations associated with pontine lacunar lesions." J Neuropsychiatry Clin Neurosci 25(2): 153-156.
- Teunisse, R. J. and M. G. Olde Rikkert (2012). "Prevalence of musical hallucinations in patients referred for audiometric testing." Am J Geriatr Psychiatry 20(12): 1075-1077.
- Tomar, A. and G. Cheung (2007). "Musical hallucinations induced by drugs." Int Psychogeriatr 19(6): 1169-1172.
- Warner, N. and V. Aziz (2005). "Hymns and arias: musical hallucinations in older people in Wales." Int J Geriatr Psychiatry 20(7): 658-660.
- Williams, V. G., et al. (2008). "Musical hallucinations after left temporal lobectomy." Cogn Behav Neurol 21(1): 38-40.
- Woo, P. Y., et al. (2014). "Monoaural musical hallucinations caused by a thalamocortical auditory radiation infarct: a case report." J Med Case Rep 8: 400.
- Zabalza-Estevez, R. J. (2014). "[Musical hallucinations: perpetual music]." Rev Neurol 58(5): 207-212.
- Zilles, D., et al. (2012). "Successful treatment of musical hallucinations with the acetylcholinesterase inhibitor donepezil." J Clin Psychopharmacol 32(3): 422-424.