|Year : 2015 | Volume
| Issue : 3 | Page : 188-189
Migraine and auditory hallucination in an adolescent
Guru S Gowda, Preeti Kandasamy, John Vijay Sagar Kommu
Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, Karnataka, India
|Date of Web Publication||1-Dec-2015|
Guru S Gowda
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
Migraine is a primary headache disorder. It includes transient aura symptoms that occur before the headache phase. Auditory hallucinations are very infrequently reported as part of migraine and are a very rare presentation. We report a 15-year-old nonpsychotic adolescent boy who has had migraine and auditory hallucinations for the past 6 years, and it worsened over the last 2 months, which was closely correlated with the severity, frequency, and duration of episodes of symptoms. The auditory hallucinations and the migraine attacks disappeared together under prophylaxis with tab. topiramate. This report suggests the possibility of auditory hallucinations as an acoustic aura in migraine attacks.
Keywords: Adolescent, auditory hallucination, headache, migraine
|How to cite this article:|
Gowda GS, Kandasamy P, Kommu JV. Migraine and auditory hallucination in an adolescent. J Med Soc 2015;29:188-9
| Introduction|| |
Migraine is a primary headache disorder that has been recognized since antiquity. The main clinical feature of migraine is intense unilateral throbbing episodic headache. This includes transient aura symptoms involving neurologic, gastrointestinal, and autonomic systems, and occurs before the headache phase. Concurrent occurrence of migraine and auditory hallucinations is extremely rare and infrequently reported as part of migraine. Only a few case reports and case series have reported that there might be a possible association between auditory hallucination and migraine in nonpsychotic child as well adult populations. ,,
| Case Report|| |
A 15-year-old adolescent from a South Indian family of upper socioeconomic status with an urban background, academically a high achiever, and a developmentally easy child with no significant past or family history, presented with a history of hearing voices in isolation of 6 years' duration. The voices were reported to be clear, arriving from an outside space, continuous, and not under his control. The content of the voices was mainly day-to-day conversation with family members, teachers, his class, and his peer group. No derogatory content was present, but the family noticed him acting out behaviour is in response to the voices. This lasted for 5-15 min, for which he was treated with antidepressants and antipsychotics for an adequate period and dose, but with poor response. On clarification, the child was also found to have had a history of intense headache of episodic type, pulsatile in nature, initially starting in the occipital area, progressing to the bitemporal area, lasting for 6-10 h. It was preceded by a blurring of vision, nausea, vomiting, and photophobia; this was relieved with analgesic medication and sleep, aggravated by walking along stairs or routine activities. The frequency varied in the range of 1-3 episodes per month, which qualifies for migraine with aura symptoms as per International Classification of Headache Disorders (ICHD) of the International Headache Society.  The voices were heard just before, during, and sometimes after these headache episodes. There was recent worsening of headache episodes for the past 2 months that temporally correlated with worsening of auditory hallucinations in frequency, severity, and duration. In addition, the adolescent had secondary depressive symptoms, namely irritability and sleeping problems, suicidal urges, suicidal ideation, and auditory hallucinations during headache episodes without core depressive cognition or low mood. Its a kind of sociocultural expression of severity of pain rather than real intent to kill himself. There was no history of head injury, substance/drug use, or psychiatric disorder except one episode of febrile seizure at the age of 4 years. Assessment was done with the help of (M.I.N.I International Neuropsychiatric Interview for Children and Adolescents) MINI-KID, Screen for Child Anxiety Related Disorders (SCARED), and Childhood Depression Inventory (CDI) to elicit psychopathology; which all turned out to be negative in scale items including anxiety, depression, and psychotic symptoms.
On admission, detailed physical and neurological examinations were not suggestive of any neurological disorder. Ophthalmological evaluation revealed refractory error, for which the patient was already using corrective spectacles. On the mental status examination, he was restless, and secondary depressive symptoms during migraine episodes without any depressive cognition and second-person, well formed, multiple auditory hallucinations were noted. Diagnostic laboratory investigations such as cerebrospinal fluid (CSF) analysis, electroencephalogram (EEG), magnetic resonance imaging (MRI)-brain, electrocardiogram (ECG), echocardiogram, electrolytes, renal and liver profile, blood sugar, thyroid function, lipid profile, and complete hemogram investigations were normal. In liaison with a neurologist, for the management of migraine, the patient was started on tab. topiramate 25 mg, which was increased to 37.5 mg/day and tab. escitalopram 20 mg/day. The patient was asked to maintain a mood/headache/thought and hallucination diary. Auditory hallucinations used to occur before and during migraine attacks. Migraine and auditory hallucinations disappeared together under prophylaxis with tab. topiramate over a period of 2 weeks, and improvement was noticed in both secondary depressive symptoms and biopsychosocial functioning.
| Discussion|| |
Migraine and psychiatric illness are highly prevalent conditions across age groups and they often cooccur. Both clinical and population-based sample studies show a well-documented association between migraine and mental health disorders. A recent review by Fabio Antonaci on migraine and psychiatric comorbidity showed an increased risk of affective and anxiety disorders in patients with migraine compared to nonmigrainous subjects. There would also be a trend toward an association of migraine with bipolar disorder, but not with substance abuse/dependence. 
In this case, auditory hallucinations were present in the absence of other perceptual abnormalities, delusions, disturbed thinking, or other cognitive or psychotic symptoms, rendering the diagnosis of psychotic disorder most unlikely. Migraine episodes closely correlated with severity, frequency, and duration of auditory hallucinations as per history and diary records, and both were resolved with conventional migraine prophylaxis with topiramate. This suggests a close relationship between the auditory hallucinations and the migraine that may include the possibility of auditory hallucinations as acoustic aura in migraine attack.
The patient felt like killing himself and experienced suicidal ideation during migraine with aura episodes; these symptoms are similar to existing evidence from an earlier population-based study in 2009 on 13-15-year-old adolescents. The same study also found an increased risk of suicidal ideation among those with migraine with aura and increased frequency of migrainous attacks, compared to the group having migraine without aura. 
The principle aim in management of auditory hallucinations in migraine includes early recognition of symptoms; excluding organic pathology and substance use; and addressing the underlying condition, such as migraine, rather than the hallucinations itself or the secondary associated symptoms.
| Conclusion|| |
Only a few cases of auditory hallucinations have been described in children and adults without psychosis who were suffering from migraine. The prognosis of independent auditory hallucinations may be favorable if the migraine is properly treated. Research is needed to explore the pathophysiological mechanism of auditory hallucinations as aura in migraine.
We would like to thank the patient and his parents for permitting us to publish the findings as a case report.
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Conflicts of interest
There are no conflicts of interest.
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