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A 29-year-old man presented to the ENT specialist for severe headache, auditory hallucinations and dizziness. The patient had a family history of both epilepsy and migraine. He never had any psychiatric disorder; however, he experienced an epileptic attack with the loss of consciousness followed by severe headache, nausea and dizziness, at least once every 2-3 years. He also experienced ‘plopping’ sounds followed by voices of different people from his family and friend circle, lasting for a few minutes accompanied by severe headache and nausea. These attacks were quite frequent (at least once a week) and headache lasted for more than 1-2 days. The headache was never accompanied by an aura.
The most likely diagnosis of this presentation is:
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 occurs as “hearing voices”. The cognitive mechanisms underlying AVH include poor self-monitoring where internally-generated (thinking) speech is falsely identified as an external sound. Though AVH is a core symptom of schizophrenia, they can also affect healthy individuals, as a symptom associated with a psychotic disorder, stress disorder, trauma complication, borderline personality disorder, hearing disability or autism. Evidence from the previous study has shown the prevalence of 0.17% for AVH in migraine patients.
The cortical spreading depression of migraine aura may be the reason behind the triggering of auditory verbal hallucinations (AVH) in this patient. The patient was suggested antimigraine triptan medication which provided him unequivocal improvement for seizures and migraine attacks.
Initial assessments included a physical exam, questionnaire and assessment of family and medical history. Varieties 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 related symptoms. Imaging studies showed no structural abnormalities in the cerebrum, suggesting the absence of brain lesions and normal hearing function and EEG showed unspecific abnormalities, not fully supporting the diagnosis of epilepsy. Audiogram turned out to be normal. The patient had used carbamazepine 600 mg every day since his first grand mal at 14.
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 was improved, and he reported only one mild migraine attack and complete absence of epilepsy during these six months of treatment. Later, the dose of valproic acid was increased to 1000 mg/day for a further six months, and carbamazepine was discontinued entirely. Post-one-year follow-up, he has not experienced any seizures and migraine attacks with AVH.
It is a rare phenomenon to experience migraine and hallucinations together. Although the exact mechanism is not known, altered regional blood flow is like to cause the same. Individual studies have reported rare associations 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 and staying away from noisy environment. Migralepsy 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.
Although the AVHs in association with migraine are extremely rare, a careful and differential diagnosis is essential. Moreover, in case of headache and nausea symptoms immediately following AVH, migraine treatment can resolve hallucinations.
Schizophr Res.2016 Apr;172(1-3):222-3.
Auditory hallucinations preceding migraine, differentiation with epileptic origin: A case report
Vreeburg SA et al.
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