![]() The risk factors for musical hallucinations are also complex and diverse (Table (Table1 1). However, apart from those specific areas, the vast brain network involved in their mediation seems to comprise auditory areas, basal ganglia, brainstem, pons, tegmentum, cerebellum, hippocampi, amygdala, visual areas and, in some cases, perhaps also the peripheral auditory system ( 4). A magnetoencephalography (MEG) study in one individual with musical hallucinations and hearing loss indicates involvement of right temporoparietal areas ( 6), whereas a more recent MEG study in a similar patient indicates involvement of the left anterior superior temporal gyrus, motor cortex, posteromedial cortex, and left lateral orbitofrontal cortex at the onset of hallucinations after a residual inhibition paradigm ( 7). The pathophysiology of such hallucinations is probably diverse and certainly needs further elucidation. Experienced clinicians report relatively frequent encounters with people experiencing them ( 4), and a survey among patients referred for audiometric testing found musical hallucinations in 3.6% of the cases ( 5). The prevalence of musical hallucinations seems to be higher than traditionally suspected, even when taking into account a review by Cope and Baguley ( 3) who reported their presence in almost 1% of individuals in a population with acquired hearing loss. Therefore, the term “idiopathic musical hallucination” is used to describe such cases, in contrast to those which are attributed to demonstrable underlying pathology, i.e., symptomatic musical hallucinations. ![]() Insight is often intact and, apart from hearing loss or tinnitus, most patients display no additional comorbidity. When first perceiving musical hallucinations, people tend to attribute them to an external source but, within a few days, most realize that the music originates from “within” their head. However, by definition, they are perceptual in nature and thus different from the “earworms” or “tunes in the head” that we all experience at times ( 2). They can be perceived within the head, or as though emanating from the environment. Musical hallucinations (also known as musical hallucinosis, auditory Charles Bonnet syndrome, and Oliver Sacks’ syndrome) are characterized by hallucinated songs, tunes, melodies, harmonics, rhythms, and/or timbres ( 1). ![]() Based on these two case descriptions and an overview of studies describing the use of acetylcholinesterase inhibitors in similar patients, we discuss possible mechanisms and propose further research on the use of acetylcholinesterase inhibitors for musical hallucinations experienced in concordance with hearing loss. Both patients were successfully treated with the acetylcholinesterase inhibitor rivastigmine. We present two female patients (aged 76 and 78 years) both of whom suffered from hearing impairment and practically incessant musical hallucinations. Although their etiology and pathophysiology appear to be heterogeneous and no evidence-based treatment methods are available, case reports indicate that acetylcholinesterase inhibitors may yield positive results in patients with comorbid hearing loss. ![]() Musical hallucinations are relatively rare auditory percepts which, due to their intrusive nature and the accompanying fear of impending mental decline, tend to cause significant distress and impairment. ![]()
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