Sharp Waves: ILAE's epilepsy podcast
Sharp Waves: ILAE's epilepsy podcast
Music, epilepsy, and the brain: Dr. Phillip Pearl & Prof. Nigel Osborne
Music can affect emotions, spark memories, and influence mood. In cases of musicogenic epilepsy, music can trigger seizures. In other cases, music may reduce seizure frequency. Dr. Cecilie Nome talks with Dr. Phillip Pearl and Prof. Nigel Osborne about the power of music and its effects on the brain.
Links:
Personalised music as a treatment for epilepsy - Epilepsy & Behavior
Sharp Waves episodes are meant for informational purposes only, and not as clinical or medical advice.
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Hey, listeners, this episode includes an audio description of an EEG recording. The episode is also available on video on the ILAE YouTube channel, where you can see the recording as it's described.
[00:00:00] Dr. Cecilie Nome: Hello everyone. And welcome to this new episode of Sharp Waves, the podcast from the International League Against Epilepsy. My name is Cecilie Nome and I will be your host in this episode. And today we have a very interesting and also very familiar topic that I think that many people can relate to in one way or another.
We will actually talk about music and epilepsy. We have two very experienced and very nice professors here today. So if you'd like to introduce yourself, maybe Dr. Pearl, maybe you could start.
[00:00:38] Dr. Phillip Pearl: Okay, thanks, Cecilie. So, I'm Phillip Pearl. I'm the Director of Epilepsy and Clinical Neurophysiology and the William Lennox Chair in the Department of Neurology at Boston Children's Hospital and Professor of Neurology at Harvard Medical School, where I'm sitting here in Boston.
And I'm also involved in the Music and Health Institute at the Berklee College of Music. And I'm also in three jam sessions a week. So I happen to be a professional, or at this point in my life, you might say semiprofessional jazz musician. I ended up attending the Peabody Conservatory of Music in Baltimore, where I grew up. My dad was a professional jazz musician and I'm a conservatory trained percussionist. My major was percussion. And at this point I play jazz, piano, vibes, and drums whenever I get a chance in the midst of my medical life, but I have found it quite nice to be able to combine music and medicine.
I think creativity is kind of the, one of the great frontiers of neuroscience. If we can study creativity, we can learn a lot about the brain and a lot about ourselves and humanity and maybe help the future of the world. But combining things such as neurology and music, or music and neuroscience, that is a way of really being creative. And so that's pretty much the basis for me sitting here speaking with you right now and Nigel, who is, as far as I know, is a true scholar of music.
[00:02:08] Prof. Nigel Osborne: I try to be a true scholar, as true as I can be. I'm something like the mirror reverse image of Phillip. I'm a musician, a composer. I've also worked in jazz, but my main focus has been opera and symphonic music. I'm emeritus professor at University of Edinburgh of music and human sciences. I stole that name from one of my mentors, Niko Tinbergen. And at the same time, for reasons far too long to explain here, I also have a background in neurology. And my main work at the moment is I work with children who have post-traumatic stress disorder. I'm mostly based in Ukraine at the moment, but I have large projects in the Middle East in, in Lebanon and in, in Israel and the Palestinian National Authority.
I came to epilepsy through my association with a wonderful neurologist called Michael Trimble, who was at Queen's Square, and we ran a number of topics on music in the brain. And Michael and a neurologist called Dale Hesdorffer from Columbia, wonderful epidemiologist of epilepsy, said, “Is there something we can do about nighttime seizures in children with music?” And I said, well, I think we probably can. And I think I have a technology that we do that might be able to help with that. And that's been very successful. We're getting very good results.
So I'm very happy to be on this this, this platform and honored to be with Phillip.
[00:03:34] Dr. Cecilie Nome: Thank you so much, that's great. And I mean, you both have such an amazing background and combining neurology and music and also a bit of neuroscience. I think that sounds absolutely perfect.
Okay, so I guess my first question will be, when you listen to music, what happens in the brain? Like, how does it affect the brain? And are there any differences when it comes to ages? Is it different between kids and older people?
[00:04:04] Prof. Nigel Osborne: Shall I kick off? I mean, with an overview. Yes, I mean, it's very likely that music was in our human evolution at a very early stage or something like music. Because a lot of our brain seems to have grown to be very music friendly. In fact, the whole brain. So when you say what is affected in the brain, well, the whole brain.
There is intensive activity in the oldest part of the brain, the brainstem, then a great deal of subcortical activity. The brainstem being our reflexive immediate responses, the subcortical area, our feelings and emotions, and of course the neocortical area dealing with the processing of the information and reflection on it in various ways. So loads and loads of areas of the brain light up. If you do an fMRI of somebody listening to music, you see an awful lot of evidence of the brain being very, very busy.
[00:04:52] Dr. Phillip Pearl: Yeah, I mean, Professor Osborne has it just right. You know, there's not really a musical locus. Neurologists are obsessed with localization. Where's the lesion? In fact, much of neurology, traditional neurology, was lesional. If someone lost their expressive language, well, that became Broca's area because of Paul Broca or receptive language, Wernicke's area.
Well, now, of course, neurology has gone from a lesional field in terms of localization to a functional field, because we have functional imaging, where we can image a brain during a function, as Professor Osborne said. And we've learned that music activates widespread areas of the brain. If someone has a amusia from a stroke, they have a stroke and they lose their sense of music. Or they have a musicogenic seizure, where a seizure is triggered by music, it's usually the right hemisphere. In fact, musicogenic seizures are usually the right temporal lobe. Recent stereo EEG depth recordings have shown that musicogenic seizures tend to be the mesial right temporal lobe structure, such as the amygdala and the hippocampus. But we also know that music just activates widespread areas of the brain, cerebrum, basal ganglia, cerebellum, limbic system, because of the emotional involvement. By that I mean the amygdala, the entorhinal cortex, the orbitofrontal cortex.
[00:06:12] Prof. Nigel Osborne: Yes. And just to add, I mean, hearing is the fastest firing system of perception as well. We know most about sound, more about sound than anything else. Vision is a generalized information. Music is, you know, frequency spike by spike. So there is that intimacy about it.
On the age question, I think that our musical brains are universal. However, our experience changes it. And through experience, through taste, but also through what we're used to hearing and listening to, and the pathways that we beat through the jungle, you know, in order to understand certain kinds of pictures and structures.
[00:06:48] Dr. Phillip Pearl: Well, I'm so glad that you brought up age here, because it's startling even in prematures, all the way to older adults, there's all kinds of evidence about the neuroplasticity of the brain.
In fact, I'd like to explain a little bit of this, because there's some really fascinating recent imaging studies using diffusion weighted imaging on MRI. Showing that premature babies, so we're talking like 34, 35 weeks, that are exposed to something like eight minutes of music twice a day, compared to those who just got headphones put on their head and didn't hear music, that there is advanced myelination shown in the white matter, and advanced complexity of neuronal connections in the gray matter, like more dendritic arborization, stuff like that. At that age. It's unbelievable. So the anatomy is there as, as Nigel said, but myelination is really very active in the first two years of life.
And then it does continue all the way through our first decade, second decade. Third decade in our 20s, and even a little bit in the fourth decade, we don't really develop our full executive function skills until we're in our late 20s or 30s. There's a wonderful group in Hanover, Germany that's done a lot of research in music. They did a study where they found in concert pianists, that if you started piano lessons before the age of nine, you were relatively protected from overuse dystonia. In other words, musician's dystonia, the movement disorder, from using our fingers in a way that the human hand was not meant to be used.
And then there was a study published in the Annals of the New York Academy of Science or something where they took older adults, by older it was ages 65 and up, and they gave them six months of piano lessons. And they compared it to another age-controlled group who had a music appreciation course, where they sat around and listened to music and talked about it, but didn't actually take piano lessons. And they found that after six months of piano lessons, older adults had increased size of their temporal cortex.
So, the fact that music changes the brain and the brain shows plasticity is at all ages. This is dramatic. This has gotten my colleagues and my own wife to take piano lessons.
[00:09:13] Dr. Cecilie Nome: I had no idea that music could really affect so many things in the brain. And, and not to mention that it could start that early. And maybe I should also start to take piano lessons.
Now we talked a lot about brain circuits and parts of basically the entire brain, I think, more or less is involved in this. What happens with those places when you listen to music, if you have epilepsy?
[00:09:37] Prof. Nigel Osborne: The basic thing is people with epilepsy seem to react to music as everybody else does. But there are exceptions. We've mentioned musicogenic epilepsy. There's also an epilepsy, ADEAF, which you may have come across—Autosomal Dominant Epilepsy with Auditory Features, which can be provoked by sounds and indeed may create illusions of sounds. So there are some exceptions, but on the whole, I think it's a fairly normal response.
We've had a lot of success with music and treating epilepsy with wide range of structures, timbres, frequency ranges and we have found the effects on all of our patients benign. I mean, we have an exclusion of people with musicogenic epilepsy and anybody else that might suffer from our treatment. But generally speaking it seems to be a benign relationship and a relationship capable of helping people with epilepsy in two ways. One is that we have a lot of evidence that music can help entrain electrical activity of the brain. There's a huge raft of it on people like Isabelle Peretz, the Canadian Montreal group, lots and lots of really good evidence and in great detail.
So if we can, we identify a personalized repertoire that will help people to regulate their own brain activity. We can do that with music.
Secondly, music is, because of its omnipresence in the brain and its capacity to modulate many things in the brain, we can also look at some of the underlying things in epilepsy, the emotional, the subcortical elements that might be playing. For example, ironically, and please, Professor Pearl will correct me on this because I have little knowledge of musicogenic epilepsy, but what I've read about it seems to suggest that sometimes the origins are quite emotional, they're quite subcortical. So we have an ambiguous situation there, where music can both interfere, and as well, it proves that it can also modulate in beneficial ways.
[00:11:42] Dr. Phillip Pearl: So this is the EEG of a patient of mine. These are the brainwaves of a 11-year-old young man who's having a musicogenic seizure. So he's in our epilepsy monitoring unit.
And panel A is page 1 and panel B is page 2. Now between each green line here is one second of time. You can see the EKG channel, that's familiar to most people. The electrocardiogram is the heart beating along about one to two times per second. And then this is the montage or the array of electrodes over the brain. In the U.S. we do the left hemisphere over the right.
And what happened is we said, give us a song that will give you a seizure. And he said, well, the introduction to the song, it's by the group Aha, which I think is a European group. They have this song called Take On Me or something like that. It has a nice introduction that's very rhythmic. And he said, “As soon as I hear this rhythm, I go into a seizure.” In fact, he was attending a parochial school and they would have choir in the morning and he had to be excused from choir class because when the choir would clap at this rhythm, he would go into a massive seizure.
Now as long as he was taking his medication, which in this case was oxcarbazepine, which is a sodium channel blocker used for focal onset epilepsy, he would not generalize into a tonic clonic or grand mal seizure. But even with the medication, he would have an aura and a seizure.
So the music starts playing and right here at the vertical line, you can see a buildup of a rhythmic discharge over the right temporal lobe, specifically phase reversing over the T8PA channel, which is the mid to posterior part of the right temporal lobe. So right here, he's having, this is what a seizure looks like on the brain. It's an electrical storm. And it's a rhythmic buildup of fast activity, and here it goes into the next page, and it builds up now over the rest of the right temporal lobe.
Now, I learned from Oliver Sacks’ wonderful book, Musicophilia, that a lot of people who have musicogenic seizures, they tend to be songs that are like something from their childhood. I haven't personally found in my patients with musicogenic seizures that it's an early childhood experience. I find for some people, it's always the same song. For this kid, it was always the same rhythm. For some people, it could be like any music. For other people, it's a certain genre of music. So I haven't really found a clear pattern in my clinical experience, but it can be a pretty debilitating epilepsy.
And in this particular patient that I showed you his EEG, he stopped having musicogenic seizures and started having audiogenic seizures, which means any sound created a seizure, and then he started having auditory seizures, which meant during the seizure he heard sounds. He had auditory hallucinations, a hallucination being something you're hearing that's not really there.
So music and epilepsy has a fascinating relationship. And now we're talking about kind of a negative relationship, where it's inducing the seizure or the seizures manifest by music. But as Professor Osborne said, there's also a potential therapeutic relationship. Music can be incredibly therapeutic. I mean, it doesn't take long to go into a nursing home and play piano, like I used to do when I was a kid, and see how people with dementia, they react to music, they get activated, they may remember the lyrics of something and start singing in a way that they hadn't shown in years.
So there's no question that music can be therapy. I mean, the whole field of music therapy is based on this and there's no question in my mind music is therapeutic for dementia, which frankly is the scourge of our time as the population keeps aging, you know, because we're living longer. Music probably has benefits and other neurologic conditions Huntington's Parkinson's, maybe Tourette syndrome, epilepsy.
Well, then we get into the Mozart effect. And to me, that is a very unproven kind of shaky area. Maybe I'll just leave it at that right now. So, you can continue to ask questions or maybe Professor Osborne wants to make a further comment.
[00:15:57] Dr. Cecilie Nome: When I was planning this episode, I was trying to look into music and epilepsy and there was quite a lot of papers on where they have looked into Mozart's music, and I think it was particularly Sonata K448 which had shown to reduce epileptic activity in the brain. Would you like to comment upon this? What is so special with this music?
[00:16:22] Prof. Nigel Osborne: Well, I share Professor Pearl’s skepticism. Not about the results, but the reasons. I think that the Mozart effect is misleading. I think that it happens that Mozart was writing music at a time when there was a certain way of structuring music in terms of its formal structures, its frequencies, its harmonicities, its internal nature that happens to be quite regulating for most people's electrical activity in their brains. But it doesn't have to be Mozart. It could be any composer from that time with a similar clarity, symmetry, transparency.
Definitely, as I said before, we have a whole ton of evidence that music can entrain electrical activity. By entrainment, I'm talking about Huygens principle of the pendulums in Paris that eventually swing together in time. So with those kinds of processes there seems to be a very direct effect of musical intellectual activity. I believe that of course, and we work on it in my own work. But I don't think it's particularly Mozart.
The treatment that I've been developing with Michael Trimble and others is more personalized. We take an overnight EEG. We look for the passages of sleep that have least epileptiform activity—the healthiest. We then ordify that directly, not sonify, ordify the frequencies directly. And we search the world's repertoire for the music that most resembles the healthy behavior of that individual's brain. And we make playlists of that. And we score much higher than the Mozart effect on that. And I think it's because it's personalized. I think Mozart happens to be, to have hit a midpoint that might affect quite a lot of people in terms of a regulatory capacity on electrical activity in the brain.
[00:18:15] Dr. Phillip Pearl: I can't add too much to that. I mean, the Mozart effect I think became kind of a popular cultural phenomenon or concept over 30 years ago when a small group of young adults had better performance or something like their performance IQ and it's just a small group and that's sort of got transmuted into people deciding that if a baby heard Mozart while a fetus they would be smarter, which wasn't based on any data at all. It's just a thought.
Now, there have been studies, and people are, Barbara Jobst’s group, for example. She's at Dartmouth, in New Hampshire. And in fact, I have a book coming out by Cambridge University Press on music, medicine, and the neurobiology of creativity, and she wrote the chapter on this topic, on Mozart and epileptiform activity, and they did study the spike rate and the seizure rate using stereo EEG using intracranial depth electrodes to the Mozart effect and various people, various centers have reported a decrease in the number of seizures, decreased number of spikes from listening to Mozart.
But first of all, the studies are really pretty small and uncontrolled and it could be anyone, we don't even know whether it's Mozart or Haydn. And then some people have said men have different effects than women. I mean, the results are all over the map. So it is really difficult and meta-analyses have been done and published recently to try to put this together. And it's all very inconclusive.
[00:19:50] Prof. Nigel Osborne: I mean, there are many other things in the Mozart studies. Also, there's been an inconsistency and lack of information. Where is the quality of life? I mean, counting spikes doesn't tell, I mean, I'm not an epileptologist, I'm an amateur one, but counting spikes doesn't tell you a great deal. It's what the child is experiencing and how their life is going that matters.
And so we need proper studies on this. It's definitely got a lot of benefit in it, because how wonderful to have a non-invasive,non-pharmacological, non-surgical intervention approach to this.
I think there's something we just have to keep looking at and studying
[00:20:26] Dr. Cecilie Nome: You've been working with, is it called the X System? The thing that you worked on and set up?
[00:20:35] Prof. Nigel Osborne: Yes, it's a model of the musical brain. It was an attempt to predict musical effects with some accountability for music medicine.
What we've done is taken all the neurology, neurophysiology, neuroscience we can find, plus some of our own experiments, and modelled what happens in the brainstem. Modeled what we know about Heschl's gyrus. We know very little about the neurosurgery of Heschl's gyrus, but we know enough to model what goes in and goes out the motor cortex aspects of limbic system.
The areas where we're able to predict things are accurately are autonomic arousal and counter arousal. We are 95% accurate with that in average cases. And also vagal power. We're 85 percent accurate there. I think we can get that better.
But by adding up what these different areas of the readouts are, we put the music in, X System tells us what's likely to happen with the music for most people. It's cross cultural. We did our first trials in India. We deliberately set out to not to fall into the trap of Western cultural centrism.
I must say that when you play the playlist when our patients are asleep, music does its job anyway. Music does its job better when people are awake, when they like it. But in fact, when people sleep, and this is when we've mostly applied it, for example, we have Indian patients who have responded just as well to a classical list as they have to an Indian list.
So there's, there are universals in music, as we've said. It's rather redeeming, after all the things that we do to try and divide human beings to know that our musical brains are, are very much in synchrony, with the caveats that Professor Pearl has added of plasticity and individual changes.
But given that, the operation is entirely universal. It is a probably as much a definer of humanity as anything else.
[00:22:35] Dr. Cecilie Nome: What happens if you have to have surgery and you have epilepsy? How would this affect you?
[00:22:41] Dr. Phillip Pearl: That’s a risk with any eloquent function, so when we do epilepsy surgery, whether it's a resection or now we do a lot of laser ablations, which is heating the tissue or disconnections, we always have to test. We do electrocortical stimulation at the bedside, we always have to test to see if that part of the brain is serving some eloquent function like language or motor.
And it's the same thing with music. If someone is, say, a professional musician, or they really depend on music, I think we would have to be careful, and groups have been careful, about not resecting, say, the superior temporal gyrus, especially Heschl's area. That would really affect someone's perception of music.
This is to the point that, in adults at least, in older adolescents and adults, craniotomies are done awake, so the patient's put to sleep initially and they open the head, but then the patient is allowed to wake up in the operating room and we have them speak and listen or move. You could have them listen to music and stimulate the part of the brain and if that area is there, in other words, it's sacrificed by the stimulation, then that area would be spared.
[00:23:52] Prof. Nigel Osborne: I think it's interesting, another possible, this is very speculative, but I'm working with some neurologists at the moment on a particular case of hypothalamic hamartoma. This is where there was a tumor on the hypothalamus accompanied by removal of some brain areas around it. And seeing if we can use music to re-stimulate and also to reduce seizures because it is accompanied by seizures. So just to say that there may be, I mean, it's worthwhile where everything else has failed. Worthwhile trying, there may be some room for little, you know, minor repair jobs. Everything else has failed here, so there's nothing to lose. The great thing about music is we can't do any harm either.
[00:24:38] Dr. Phillip Pearl: That's interesting because the hypothalamic hamartoma presents with a gelastic or dacrystic seizure. Gelastic meaning a giggle or a laugh. It's not really a happy laugh. It's a mirthless laugh, but still it presents with this emotional output of a laugh or a giggle or dacrystic, tearing or crying.
And I don't think we completely understand it, but it shows you how integral the hypothalamus is to so many functions from endocrine to emotional So that's quite interesting to think about music therapy for those patients.
[00:25:10] Prof. Nigel Osborne: We're going to give it a try and let you know how we do.
We have no grandiose ideas. What music can do is very humble. And we must in this whole process, where eventually the medical profession has seen the value of music. It's very important that we don't exaggerate anything, that we keep the hardest of evidence to present and that we'd have no inflated ideas.
So I present this with care to say that this is only as a last resort in the case where nothing else can be done and it can't do any harm. So let's have a try.
[00:25:41] Dr. Phillip Pearl: Yeah. Music seems innocuous enough, but you know, it can also be very powerful because anesthesiologists have found that it can be remarkably effective for pain control and reduce people's requirement for anesthesia. As powerful as it is for us emotionally and meditatively and we think intellectually and creatively, it seems to have powerful medicinal effects.
[00:26:05] Prof. Nigel Osborne: It does. We're also going to be working on pain reduction as well, and it doesn't seem just to be distraction either. So very interesting areas for the future, I think, as long as we remain humble.
These are small-scale things we can do, but it might make the difference. And it has in one or two of the cases of our epilepsy patients and they all claim to be living better lives.
I would like to see the discipline of music medicine grow. If possible, having been a witness to its birth in this phase of our culture, of course, it was in human civilization for a long time, but at the time of the Age of Reason got buried for a bit because it didn't have the evidence that it now has to support itself.
But now we have the evidence to move forward with humbleness but in the hope of a new music medicine.
[00:26:55] Dr. Cecilie Nome: Thank you. Are there any last thing that you would like to mention or discuss for this episode?
[00:27:00] Dr. Phillip Pearl: Well, I do want to congratulate Professor Osborne on work he's doing in Ukraine and war-torn areas, because that sounds remarkable. I don't know exactly how much music's involved in that or neuroscience. But as someone working at a children's hospital, especially in developmental neuroscience, that's remarkable. You know, Beethoven wrote the “Ode to Joy” and my understanding is that was his solution to world peace. And gee, we need it now as much as then, as much as ever.
So thank you for that work. And I want to thank you, Cecilie, for putting this episode together.
[00:27:41] Prof. Nigel Osborne: Yes, I'd just like to thank you very much for your kind words, Professor Pearl, and just say what an honor it is to be here. As a young man wanting to explore music medicine I would never imagined that it would come to a point where I was able to have a discussion with such a distinguished medical practitioner. So thank you very much for that.