Hearing voices: does it give your patient a headache? A case of auditory hallucinations as acoustic aura in migraine

Figures & data

Table 1 Biopsychosocial model of case of auditory hallucinations as acoustic aura in migraine: history and diagnostic phase

Axis	History				Diagnostic phase
Time	T0	1 week	6 weeks	7 weeks	12 weeks	13 weeks + 3 days	13 weeks + 5 days
Somatic	1st migraine attack with visual aura	2nd migraine attack with visual aura	Biweekly migraine attack with and without visual aura	Biweekly migraine with and without visual aura R/oxazepam 10 mg daily	Biweekly migraine with and without visual aura	Biweekly migraine with and without visual aura R/start mirtazapine 15 mg and later elevated to 45 mg daily	Diagnosis: migraine with visual aura No narcolepsy No epilepsy No EEG or MRI abnormalities No abnormalities of vision or hearing
Psychological	No history		1st hypnopompic Auditory hallucination Followed by headache	Anxiety, sleeplessness	Anxiety, sleeplessness, depressive symptoms Diagnostic interviews: no indications for psychosis, dissociation, or cognitive decline	2nd hypnopompic Auditory hallucination Followed by headache	Diagnosis: No psychosis Auditory hallucination as acoustic aura in chronic migraine Auditory hallucination misinterpreted as psychotic symptom
Health care use	No history			Visits GP who prescribes oxazepam daily	Patient presents at Clinical Centre for Body, Mind and Health Somatic screening by Nurse Practitioner Psychosocial interview by psychiatric nurse Semistructured clinical diagnostic interview by psychiatrist		Consultation Neurologist Somatic screening, EEG and MRI scan
Social system	40-year-old male, happily married Three kids Employed		Family upset	Visits priest who recommends prayer	System intake: Wife is afraid that patient is schizophrenic and might kill son		Diagnosis: family is afraid about the beginning of schizophrenia in patient

Abbreviations: EEG, electroencephalography; GP, general practitioner; MRI, magnetic resonance imaging.

Table 2 Biopsychosocial model of case of auditory hallucinations as acoustic aura in migraine: treatment and follow-up phase

Time	18 weeks Treatment	22 weeks Follow up	30 weeks Referral back
Somatic	R/propranolol 40 mg twice daily	Continue propranolol and mirtazapine Discontinue oxazepam No migraine attacks	Continue propranolol 40 mg No migraine attacks
Psychological	Explanation of the symptom: acoustic aura	Less anxiety and depressive symptoms No recurrence of hallucinations	Symptoms in remission
Health care use	Monitoring by Clinical Centre for Body, Mind and Health	Continued monitoring	Referral back to GP with explanation about suggested discontinuation of mirtazapine after 6 months
Social system	Explanation to patient and wife of the patient that he is not schizophrenic	Family is calming down	No events

Abbreviation: GP, general practitioner.

Table 3 Patient DSM-IV classification

Axis I: Adjustment disorder with mixed anxiety and depressed mood

Axis II No diagnosis

Axis III Migraine with Auditory Hallucination as Aura

Axis IV 0

Axis V 80/90