A case of auditory hallucinations preceding migraine, differentiation with epileptic origin
A 29-year-old man shown to the clinic complaining of severe headache, auditory hallucinations and dizziness. The patient was a well-educated, wealthy man working with a multi-national company. He had a strong family history of both migraine and epilepsy. He never had any psychiatric disorder; however, he stated to have experienced epileptic attack with loss of consciousness followed by severe headache, nausea and dizziness, at least once a year. He also experienced ‘plopping’ sounds followed by voices of different people from his family and friend circle, lasting for few minutes and followed by severe headache and nausea. These attacks were quite frequent (at-least once a week) and headache lasted for more than 1-2 days, per attack. The headache was never accompanied by any type of aura. He was taking anticonvulsant (carbamazepine 600 mg/ daily) since his first grand mal, about nine years ago.
The most likely diagnosis of this presentation is
Grand mal seizure
Auditory verbal hallucinations (AVH) are common, especially in schizophrenia, affecting approximately 70% of patients. In simple terms, AVH is defined as vocal perceptions without an appropriate external stimulus that usually occur as a “hearing voices”. The cognitive mechanisms underlying AVH include defective self-monitoring where internally-generated (thinking) speech is falsely identified as an external sound.1 Though AVH are core symptom of schizophrenia, they can also affect healthy individuals, as a symptom associated with psychotic disorder, stress disorder, trauma complication, borderline personality disorder, hearing disability or autism.1,2 Evidences from previous study have shown the prevalence of 0.17% for AVH in migraine patients.3
Initial assessments included physical exam, questionnaire and assessment of family and medical history. Variety of aspects were considered for the differential diagnosis of AVH. There was no psychiatric disorder, or drug abuse history. As AVHs were strongly associated with headaches and nausea, migraine is the predominant diagnosis. However, no formal diagnosis was made for migraine and associated symptoms. Imaging studies showed no structural abnormalities in cerebrum suggesting absence of brain lesions and normal hearing function and EEG showed unspecific abnormalities, not fully supporting the diagnosis of epilepsy. Audio-gram turned out to be normal.
The treatment was started with valproic acid, owing to its benefits for both migraine and epilepsy. An over-the-counter medicine (like NSAIDs, triptan) was recommended when experiencing AVH. With this treatment, the symptom were improved and he reported only one mild migraine attack and complete absence of epilepsy during these six months of treatment. Later, the dose of valporic acid was increased to 1000 mg/day for further six months and carbamazepine was completely discontinued. At follow up one year later, he has not experienced any seizures and migraine attacks with AVH.
Coexistence of migraine and hallucinations is extremely uncommon. The underlying mechanism is poorly understood, but it is believed to be linked with altered regional blood flow. Individual studies have reported rare associations of between migraine and AVH. Defective hearing is also rarely reported with migraine. However, their frequency and significant prevalence in patients with depression may indicate that defective hearing may or may not be a form of migraine aura, but could be a migraine trait symptom. Alternative mechanisms include perfusion changes in primary auditory cortex, serotonin-related ictal perceptual changes, or a release phenomenon in the setting of phonophobia with avoidance of a noisy environment.3 The term migralepsy was refers to a syndrome represented by an immediate migraine attack following an epileptic seizure. Migraine aura, especially AVHs in this patient was indicative of the cortical spreading depression of migraine aura causing AVH.1
Although the AVHs in association with migraine is extremely rare, a careful and differential diagnosis is important. Moreover, in case of headache and nausea symptoms immediately following AVH, migraine treatment can resolve hallucinations.
Steinmann S, Leicht G, Mulert C. Interhemispheric auditory connectivity: structure and function related to auditory verbal hallucinations. Front Hum Neurosci. 2014 Feb 11;8:55.
Vreeburg SA, Leijten FS, Sommer IE. Auditory hallucinations preceding migraine, differentiation with epileptic origin: A case report. Schizophr Res. 2016 Feb 6. pii: S0920-9964(16)30064-0.
Miller EE, Grosberg BM, Crystal SC,et al. Auditory hallucinations associated with migraine: Case series and literature review. Cephalalgia. 2015 Sep;35(10):923-30.