Musical hallucinations

By Marcello Cherchi, MD PhD

For patients

Musical hallucinations (MH) are “hearing music that’s not really there.” This can happen to people with hearing loss, some psychiatric illnesses and some neurological illnesses, though it is not known why it happens. If musical hallucinations are not bothersome, then you do not need to do anything about it. If musical hallucinations are bothersome, then some doctors will consider treatment with medications or referral for psychological counseling.

For clinicians

Overview

Musical hallucinations (MH) are well-formed auditory perceptions in the absence of any auditory stimulus. Hearing loss appears to be the most significant risk factor for MH, but it has also been reported in association with several psychiatric disorders (usually obsessive-compulsive disorder or schizophrenia) and neurological disorders. The mean age of onset is in the 7^th decade, and it is more common in females. The underlying mechanism is unknown. Management strategies include reassurance, expectant management (since some cases remit spontaneously), various medications (including anti-epileptics, anti-depressants, anti-psychotics and anti-cholinergics) and psychological treatments, though none of these interventions has been studied in a randomized controlled trial.

Introduction

The medical definition of a hallucination is a perception in the absence of any stimulus. Musical hallucinations (MH), as the name suggests, are perceptions of music in the absence of any musical stimulus. While sometimes classified under the broader category of tinnitus, musical hallucinations are complex, well-formed perceptions, not merely tinnitus with a hissing, ringing or buzzing quality. There is debate regarding whether MH and simple tinnitus are distinct phenomena, or different manifestations of a single underlying disease process (Gandhi et al. 2016).

Epidemiology

There are numerous case reports and series of musical hallucinations (MH) occurring in association with hearing loss (Ali 2002; Brunner and Amedee 2015; Fenton and McRae 1989; Marschall et al. 2023; Niranjan et al. 2017; Sanchez et al. 2011; Tanriverdi et al. 2001), and this appears to be the most significant risk factor (Colon-Rivera and Oldham 2014). This emergence of well-formed auditory hallucinations during auditory deprivation (from hearing loss) is somewhat analogous to the emergence of well-formed visual hallucinations during visual deprivation (from vision loss), which has given rise to the idea that musical hallucinations are the auditory analogue of Charles Bonnet syndrome (Aziz et al. 2004; Serrador-García et al. 2012; Singh et al. 2019).

Some literature cites a female preponderance of MH, ranging from 70% (Evers 2006; Evers and Ellger 2004) to 80% (Alvarez Perez et al. 2017) of cases.

Evers and Ellger conducted a literature review of cases and reported that the mean age of onset of MH was 61.5 years (Evers and Ellger 2004). Warner and Aziz report that the incidence of MH in people 65 and older is 1 per 10,000 (Warner and Aziz 2005). From statistics such as these, age greater than 60 years has been cited as a risk factor for MH (Alvarez Perez et al. 2017; Evers 2006), though it is unclear whether this risk is distinct from age-related hearing loss.

Pathophysiological mechanism of disease

The mechanism of MH is unknown (Evers 2006). Since many cases occur in the context of hearing loss, “The most accepted physiopathology of musical hallucination associated to hearing loss (caused by cochlear lesion, cochlear nerve lesion or by interruption of mesencephalon or pontine auditory information) is the disinhibition of auditory memory circuits due to sensory deprivation” (Sanchez et al. 2011).

There are reports of patients exhibiting both palinacusis (perseverant perception of an auditory stimulus after the actual stimulus has ended) and musical hallucinations, and such overlaps raises questions about whether these phenomena share a common mechanism (Terao and Matsunaga 1999).

Some investigators maintain that a component of otologic disease must be present (Cope and Baguley 2009; Gordon 1997). This strikes us as untenable since MH has been reported in patients without hearing loss or any other evidence of otologic disease.

Clinical presentation

With gradually progressive hearing loss (such as age-related hearing loss), the emergence of musical hallucinations can be similarly insidious. Abrupt-onset MH has been reported in cases of sudden hearing loss (Tanriverdi et al. 2001).

Testing: auditory

Given that hearing loss appears to be a risk factor for MH, it is medically reasonable to check audiometry.

Imaging

No uniform imaging features have been identified in MH.

Differential diagnosis

MH can occur in patients after cochlear implantation (Auffarth and Kropp 2009). Low and colleagues (Low et al. 2013) studied a series of 82 cochlear implantation patient and reported that 11 patients (13%) developed MH after implantation.

MH has been reported in association with a variety of medical conditions, including.

• Psychiatric disorders.
  • Schizophrenia (Baba and Hamada 1999; Baba et al. 2003; Saba and Keshavan 1997).
  • Hermesh and colleagues (Hermesh et al. 2004) studied 190 consecutive psychiatric patients diagnosed with anxiety, affective disorders and schizophrenic disorders, and reported that, “Musical hallucinations occurred in more than one fifth of all diagnoses. The prevalence of musical hallucinations was highest in OCD [obsessive-compulsive disorder] patients (41%)” (Hermesh et al. 2004).
• Stroke (Serby et al. 2013).
• Parkinson’s disease (Mittal and Giron 2010).
• Epilepsy (Borelli et al. 2016; Coebergh et al. 2019).
• Lyme disease (Stricker and Winger 2003).

There are case reports of MH occurring after various medical procedures, including:

• Resection of brain tumors (Isolan et al. 2010; Keshavan et al. 1988) and epileptogenic temporal lobe tissue (Williams et al. 2008).
• Electroconvulsive therapy (Janakiraman et al. 2006).
• Hemodialysis (Fukunishi et al. 1998).
• Transplant (Fukunishi et al. 1999).
• Various surgical procedures (Iijima et al. 2000; Wong and Bhalerao 2010).

There are case reports of MH occurring in association with various medications, including:

• Amantadine (Gondim Fde et al. 2010).
• Amiodarone (Molinaro et al. 2022).
• Betamethasone (Kanemura et al. 2010).
• Ceftazidime (Song and Jung 2019).
• Clomipramine (Vallada and Gentil 1991).
• Imipramine (Terao 1995).
• Lorazepam (Curtin and Redmund 2002).
• Mirtazapine (Lee and Stewart 2018).
• Morphine (Davies and Quinn 2005).
• Oxycodone (Moore 2003).
• Paroxetine (Muraosa et al. 2020).
• Pramipexole (Kataoka and Ueno 2014).
• Propranolol (Fernandez et al. 1998).
• Sertraline (Costa et al. 2024).
• Tramadol (Keeley et al. 2000).
• Voriconazole (Agrawal and Sherman 2004).

We would interpret such case reports with caution, since these medications are generally being deployed to treat a pre-existing disease. For example, there are case reports of MH being “triggered” when amantadine (Gondim Fde et al. 2010) or pramipexole (Kataoka and Ueno 2014) were used to treat Parkinson’s disease, but MH can occur even in untreated Parkinson’s disease patients

Treatment and prognosis

MH can remit spontaneously (Coebergh et al. 2015), so in many cases, reassurance and expectant management are sufficient.

In cases where the underlying etiology of MH appears to be hearing loss, amplification may ameliorate symptoms; masking may also play a role in management (Colon-Rivera and Oldham 2014).

For cases in which MH arises following initiation of medication, it is reasonable to try discontinuing that medication (if medically feasible).

Literature regarding pharmacologic treatment of MH is largely limited to case reports, including:

• Carbamazepine (Aizawa et al. 2014; Terao and Tani 1998).
• Donepezil (Ukai et al. 2007; Zilles et al. 2012).
• Escitalopram (Bergman et al. 2014).
• Gabapentin (Holroyd and Sabeen 2008).
• Lamotrigine (Huntley et al. 2011).
• Olanzapine (Mansoor and Ganzini 2014; Peritogiannis et al. 2016).
• Quetiapine (David and Fernandez 2000; Kitamura et al. 2017; Mansoor and Ganzini 2014).
• Risperidone (Peritogiannis et al. 2016).
• Rivastigmine (Blom et al. 2015).

Other treatment modalities reported include repetitive transcranial magnetic stimulation (Cosentino et al. 2010; Nordberg et al. 2021) and various cognitive approaches (Shergill et al. 1998).

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