Background: Despite an increased scientific interest in musical hallucinations over the past 25 years, treatment protocols are still lacking. This may well be due to the fact that musical hallucinations have multiple causes, and that published cases are relatively rare.Objective: To review the effects of published treatment methods for musical hallucinations.Methods: A literature search yielded 175 articles discussing a total number of 516 cases, of which 147 articles discussed treatment in 276 individuals. We analyzed the treatment results in relation to the etiological factor considered responsible for the mediation of the musical hallucinations, i.e., idiopathic/hypoacusis, psychiatric disorder, brain lesion, and other pathology, epilepsy or intoxication/pharmacology.Results: Musical hallucinations can disappear without intervention. When hallucinations are bearable, patients can be reassured without any other treatment. However, in other patients musical hallucinations are so disturbing that treatment is indicated. Distinct etiological groups appear to respond differently to treatment. In the hypoacusis group, treating the hearing impairment can yield significant improvement and coping strategies (e.g., more acoustic stimulation) are frequently helpful. Pharmacological treatment methods can also be successful, with antidepressants being possibly more helpful than antiepileptics (which are still better than antipsychotics). The limited use of acetylcholinesterase inhibitors has looked promising. Musical hallucinations occurring as part of a psychiatric disorder tend to respond well to psychopharmacological treatments targeting the underlying disorder. Musical hallucinations experienced in the context of brain injuries and epilepsy tend to respond well to antiepileptics, but their natural course is often benign, irrespective of any pharmacological treatment. When intoxication/pharmacology is the main etiological factor, it is important to stop or switch the causative substance or medication.Conclusion: Treatments for musical hallucinations tend to yield favorable results when they target the main etiological factor of these phenomena. There is a need to establish the natural course of musical hallucinations, their response to non-pharmacological treatments, and their effects on the patient's quality of life. There is also a need to standardize the assessment of treatment responses, and document long-term follow up.

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. 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. We present two female patients (aged 76 and 78 years) both of whom suffered from hearing impairment and practically incessant musical hallucinations. Both patients were successfully treated with the acetylcholinesterase inhibitor rivastigmine. 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.

Musical hallucinations are poorly understood phenomena. Their relation with epilepsy was first described over a century ago, but never systematically explored. We, therefore, reviewed the literature, and assessed all descriptions of musical hallucinations attributed to epileptic activity. Our search yielded 191 articles, which together describe 983 unique patients, with 24 detailed descriptions of musical hallucinations related to epilepsy. We also describe six of our own patients. Based on the phenomenological descriptions and neurophysiological data, we distinguish four subgroups of epilepsy-related musical hallucination, comprising auras/ictal, inter-ictal and post-ictal phenomena, and phenomena related to brain stimulation. The case descriptions suggest that musical hallucinations in epilepsy can be conceptualised as lying on a continuum with other auditory hallucinations, including verbal auditory hallucinations, and—notably—tinnitus. To account for the underlying mechanism we propose a Bayesian model involving top-down and bottom-up prediction errors within the auditory network that incorporates findings from EEG and MEG studies. An analysis of phenomenological characteristics, pharmacological triggers, and treatment effects suggests wider ramifications for understanding musical hallucinations. We, therefore, conclude that musical hallucinations in epilepsy open a window to understanding these phenomena in a variety of conditions.