Detailed clinical characteristics of musical hallucinations in 81 patients

Musical hallucinations are perceptions of music without an external source. Approximately 500 publications on this topic have appeared over the past 35 years. Prior literature has largely consisted of case reports and small series, with only limited systematic studies on the characterisation of mixed pathology, relation to hearing loss, spatial localisation, and multimodal features.

We conducted a retrospective analysis of baseline data from a prospective cohort study of 81 individuals experiencing musical hallucinations. Participants underwent assessment with the Musical Hallucinations (MuHa) Questionnaire-a tailored, non-validated semi-structured survey/interview-alongside additional questionnaires, EEG, neuroimaging, and audiological testing. The present analysis focuses on baseline phenomenological characteristics derived from the MuHa Questionnaire in 80 eligible participants. Analyses were exploratory and descriptive.

Mean age was 65 years, with a slight female predominance. Hallucinations were most often perceived as internal, while external localisation was more common with familiar music and in individuals with (asymmetric) hearing loss. Underlying causes included psychiatric disorders (50%), hearing loss (50%), structural neurological changes (28%), and frequently combinations thereof (28%). A notable new finding was the high prevalence of tinnitus and multimodal hallucinations, involving up to six sensory modalities; these were generally associated with internal localisation, except in isolated hearing loss. Musical content spanned multiple genres, most commonly religious music. Hallucinations were considered burdensome in over 65% of the cases, and most participants reported little control; behavioral strategies such as distraction or listening to external music provided only temporary relief in about 20%.

Musical hallucinations may be more common than previously appreciated within broader multimodal perceptual syndromes and mixed etiologies, suggesting a more distributed pathophysiology than traditionally assumed. Their burden and limited controllability highlight the need for further mechanistic and therapeutic research.