Have you ever heard something that others cannot – such as your name being called? Hearing voices or other noises that aren’t there is very common. About 10% of people report experiencing auditory hallucinations at some point in their life.

The experience of hearing voices can be very different from person to person, and can change over time. They might be the voice of someone familiar or unknown. There might be many voices, or just one or two. They can be loud or quiet like a whisper.

For some people these experiences are positive. They might represent a spiritual or supernatural experience they welcome or a comforting presence. But for others these experiences are distressing. Voices can be intrusive, negative, critical or threatening. Difficult voices can make a person feel worried, frightened, embarrassed or frustrated. They can also make it hard to concentrate, be around other people and get in the way of day-to-day activities.

Although not everyone who hears voices has a mental health problem, these experiences are much more common in people who do. They have been considered a hallmark symptom of schizophrenia, which affects about 24 million people worldwide.

However, such experiences are also common in other mental health problems, particularly in mood- and trauma-related disorders (such as bipolar disorder or depression and post-traumatic stress disorder) where as many as half of people may experience them.

Why do people hear voices?

It is unclear exactly why people hear voices but exposure to prolonged stress, trauma or depression can increase the chances.

Some research suggests people who hear voices might have brains that are “wired” differently, particularly between the hearing and speaking parts of the brain. This may mean parts of our inner speech can be experienced as external voices. So, having the thought “you are useless” when something goes wrong might be experienced as an external person speaking the words.

Other research suggests it may relate to how our brains use past experiences as a template to make sense of and make predictions about the world. Sometimes those templates can be so strong they lead to errors in how we experience what is going on around us, including hearing things our brain is “expecting” rather than what is really happening.

What is clear is that when people tell us they are hearing voices, they really are! Their brain perceives voice experiences as if someone were talking in the room. We could think of this “mistake” as working a bit like being susceptible to common optical tricks or visual illusions.

Coping with hearing voices

When hearing voices is getting in the way of life, treatment guidelines recommend the use of medications. But roughly a third of people will experience ongoing distress. As such, treatment guidelines also recommend the use of psychological therapies such as cognitive behavioural therapy.

The next generation of psychological therapies are beginning to use digital technologies and virtual reality offers a promising new medium.

Avatar therapy allows a person to create a virtual representation of the voice or voices, which looks and sounds like what they are experiencing. This can help people regain power in the “relationship” as they interact with the voice character, supported by a therapist.

Jason’s experience

Aged 53, Jason (not his real name) had struggled with persistent voices since his early 20s. Antipsychotic medication had helped him to some extent over the years, but he was still living with distressing voices. Jason tried out avatar therapy as part of a research trial.

He was initially unable to stand up to the voices, but he slowly gained confidence and tested out different ways of responding to the avatar and voices with his therapist’s support.

Jason became more able to set boundaries, such as not listening to them for periods throughout the day. He also felt more able to challenge what they said and make his own choices.

Over a couple of months, Jason started to experience some breaks from the voices each day and his relationship with them started to change. They were no longer like bullies, but more like critical friends pointing out things he could consider or be aware of.

Gaining recognition

Following promising results overseas and its recommendation by the United Kingdom’s National Institute for Health and Care Excellence, our team has begun adapting the therapy for an Australian context.

We are trialling delivering avatar therapy from our specialist voices clinic via telehealth. We are also testing whether avatar therapy is more effective than the current standard therapy for hearing voices, based on cognitive behavioural therapy.

As only a minority of people with psychosis receive specialist psychological therapy for hearing voices, we hope our trial will support scaling up these new treatments to be available more routinely across the country.

We would like to acknowledge the advice and input of Dr Nadine Keen (consultant clinical psychologist at South London and Maudsley NHS Foundation Trust, UK) on this article.

Leila Jameel, Trial Co-ordinator and Research Therapist, Swinburne University of Technology; Imogen Bell, Senior Research Fellow and Psychologist, The University of Melbourne; Neil Thomas, Professor of Clinical Psychology, Swinburne University of Technology, and Rachel Brand, Senior Lecturer in Clinical Psychology, University of the Sunshine Coast

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Migraine is many things, but one thing it’s not is “just a headache”.

“Migraine” comes from the Greek word “hemicrania”, referring to the common experience of migraine being predominantly one-sided.

Some people experience an “aura” preceding the headache phase – usually a visual or sensory experience that evolves over five to 60 minutes. Auras can also involve other domains such as language, smell and limb function.

Migraine is a disease with a huge personal and societal impact. Most people cannot function at their usual level during a migraine, and anticipation of the next attack can affect productivity, relationships and a person’s mental health.

What’s happening in my brain?

The biological basis of migraine is complex, and varies according to the phase of the migraine. Put simply:

The earliest phase is called the prodrome. This is associated with activation of a part of the brain called the hypothalamus which is thought to contribute to many symptoms such as nausea, changes in appetite and blurred vision.

Next is the aura phase, when a wave of neurochemical changes occur across the surface of the brain (the cortex) at a rate of 3–4 millimetres per minute. This explains how usually a person’s aura progresses over time. People often experience sensory disturbances such as flashes of light or tingling in their face or hands.

In the headache phase, the trigeminal nerve system is activated. This gives sensation to one side of the face, head and upper neck, leading to release of proteins such as CGRP (calcitonin gene-related peptide). This causes inflammation and dilation of blood vessels, which is the basis for the severe throbbing pain associated with the headache.

Finally, the postdromal phase occurs after the headache resolves and commonly involves changes in mood and energy.

What can you do about the acute attack?

A useful way to conceive of migraine treatment is to compare putting out campfires with bushfires. Medications are much more successful when applied at the earliest opportunity (the campfire). When the attack is fully evolved (into a bushfire), medications have a much more modest effect.

Aspirin

For people with mild migraine, non-specific anti-inflammatory medications such as high-dose aspirin, or standard dose non-steroidal medications (NSAIDS) can be very helpful. Their effectiveness is often enhanced with the use of an anti-nausea medication.

Triptans

For moderate to severe attacks, the mainstay of treatment is a class of medications called “triptans”. These act by reducing blood vessel dilation and reducing the release of inflammatory chemicals.

Triptans vary by their route of administration (tablets, wafers, injections, nasal sprays) and by their time to onset and duration of action.

The choice of a triptan depends on many factors including whether nausea and vomiting is prominent (consider a dissolving wafer or an injection) or patient tolerability (consider choosing one with a slower onset and offset of action).

As triptans constrict blood vessels, they should be used with caution (or not used) in patients with known heart disease or previous stroke.

Gepants

Some medications that block or modulate the release of CGRP, which are used for migraine prevention (which we’ll discuss in more detail below), also have evidence of benefit in treating the acute attack. This class of medication is known as the “gepants”.

Gepants come in the form of injectable proteins (monoclonal antibodies, used for migraine prevention) or as oral medication (for example, rimegepant) for the acute attack when a person has not responded adequately to previous trials of several triptans or is intolerant of them.

They do not cause blood vessel constriction and can be used in patients with heart disease or previous stroke.

Ditans

Another class of medication, the “ditans” (for example, lasmiditan) have been approved overseas for the acute treatment of migraine. Ditans work through changing a form of serotonin receptor involved in the brain chemical changes associated with the acute attack.

However, neither the gepants nor the ditans are available through the Pharmaceutical Benefits Scheme (PBS) for the acute attack, so users must pay out-of-pocket, at a cost of approximately A$300 for eight wafers.

What about preventing migraines?

The first step is to see if lifestyle changes can reduce migraine frequency. This can include improving sleep habits, routine meal schedules, regular exercise, limiting caffeine intake and avoiding triggers such as stress or alcohol.

Despite these efforts, many people continue to have frequent migraines that can’t be managed by acute therapies alone. The choice of when to start preventive treatment varies for each person and how inclined they are to taking regular medication. Those who suffer disabling symptoms or experience more than a few migraines a month benefit the most from starting preventives.

Almost all migraine preventives have existing roles in treating other medical conditions, and the physician would commonly recommend drugs that can also help manage any pre-existing conditions. First-line preventives include:

• tablets that lower blood pressure (candesartan, metoprolol, propranolol)
• antidepressants (amitriptyline, venlafaxine)
• anticonvulsants (sodium valproate, topiramate).

Some people have none of these other conditions and can safely start medications for migraine prophylaxis alone.

For all migraine preventives, a key principle is starting at a low dose and increasing gradually. This approach makes them more tolerable and it’s often several weeks or months until an effective dose (usually 2- to 3-times the starting dose) is reached.

It is rare for noticeable benefits to be seen immediately, but with time these drugs typically reduce migraine frequency by 50% or more.

‘Nothing works for me!’

In people who didn’t see any effect of (or couldn’t tolerate) first-line preventives, new medications have been available on the PBS since 2020. These medications block the action of CGRP.

The most common PBS-listed anti-CGRP medications are injectable proteins called monoclonal antibodies (for example, galcanezumab and fremanezumab), and are self-administered by monthly injections.

These drugs have quickly become a game-changer for those with intractable migraines. The convenience of these injectables contrast with botulinum toxin injections (also effective and PBS-listed for chronic migraine) which must be administered by a trained specialist.

Up to half of adolescents and one-third of young adults are needle-phobic. If this includes you, tablet-form CGRP antagonists for migraine prevention are hopefully not far away.

Data over the past five years suggest anti-CGRP medications are safe, effective and at least as well tolerated as traditional preventives.

Nonetheless, these are used only after a number of cheaper and more readily available first-line treatments (all which have decades of safety data) have failed, and this also a criterion for their use under the PBS.

Mark Slee, Associate Professor, Clinical Academic Neurologist, Flinders University and Anthony Khoo, Lecturer, Flinders University

This article is republished from The Conversation under a Creative Commons license. Read the original article.