Abstracts

Rationale: Musicogenic epilepsy is a subtype of reflex epilepsies. It is an unusual and oftentimes debilitating phenomenon. This case highlights the problematic treatment of the condition, and offers a novel environmental therapeutic approach.Methods: Case reportResults: A 62-year-old ambidextrous woman presented with a sixteen-year history of unprovoked spells. These spells were described as a sudden feeling of intense fear accompanied by an ominous sense of a woman present beside her. EEG performed elsewhere revealed bitemporal sharp activity. The following failed to control her spells: phenytoin, carbamazepine, gabapentin, and felbamate. One year prior to presentation, she had an abrupt change in her spells. Specifically, her spells were provoked by slow, melancholic music. They were characterized by sadness and unresponsive staring lasting minutes. The spells had occurred while singing hymns at church. When walking in the mall, she had experienced the spells while listening to ambient music in the mall. Levetiracetam was initiated for these spells, but it was discontinued due to lack of efficacy. Background EEG recorded at our Epilepsy Monitoring Unit showed right temporal spike discharges. She listened to melancholic music for 15 minutes every hour for a total of seven hours. Three of the seven trials triggered spells characterized by fear, tachycardia, crying, then confused behavior, lip smacking, and postictal nose-wiping with the right hand. Some spells were accompanied by the ominous sense of a woman beside her. As the confused behavior and lip smacking developed, rhythmic right frontotemporal sharp theta and alpha frequency discharges developed with rapid spread to the left temporal region. She was also found to have Hashimoto’s thyroiditis (TSH 8.9 mIU/L; normal of 0.3 to 5.0) and the possibility of an immune-mediated epilepsy associated with elevated TPO antibodies (868 IU/mL; normal of <40.0) was entertained though cerebrospinal fluid was normal and no benefit occurred after a course of either IV methylprednisolone or IV immunoglobulin (administered during prolonged EEG monitoring). The patient noticed that music with an upbeat, fast-tempo rhythm did not trigger seizures, and they also aborted the onset or progression of seizures triggered by melancholic music. Therefore, when she was exposed to melancholic music, such as when walking in the mall, she would turn on her portable audio player and listen to up-tempo music sung by Elvis Presley. Conclusions: Music and emotion are closely linked. Emotions precipitating seizures is a well-described phenomenon. In our patient, it seems that the slow tempo as well as the timbre and pathos expressed in the music triggered the patient’s seizures. There have been rare reports of intrusive musical hallucinations in the elderly that were attenuated paradoxically and successfully by listening to music. In our patient, musicogenic seizures were successfully prevented or terminated by counter treatment with music of a different tempo.