Epilepsia, 53(6):947–961, 2012
doi: 10.1111/j.1528-1167.2012.03523.x
CRITICAL REVIEW AND INVITED COMMENTARY
Music and epilepsy: A critical review
Melissa Jane Maguire
Department of Neurology, Leeds General Infirmary, Leeds, United Kingdom
SUMMARY
The effect of music on patients with epileptic seizures is
complex and at present poorly understood. Clinical stud-
ies suggest that the processing of music within the human
brain involves numerous cortical areas, extending beyond
Heschl’s gyrus and working within connected networks.
These networks could be recruited during a seizure mani-
festing as musical phenomena. Similarly, if certain areas
within the network are hyperexcitable, then there is a
potential that particular sounds or certain music could act
as epileptogenic triggers. This occurs in the case of musi-
cogenic epilepsy, whereby seizures are triggered by
music. Although it appears that this condition is rare, the
exact prevalence is unknown, as often patients do not
implicate music as an epileptogenic trigger and routine
electroencephalography does not use sound in seizure
provocation. Music therapy for refractory epilepsy
remains controversial, and further research is needed to
explore the potential anticonvulsant role of music. Dopa-
Music is an integral part of everyday life and culture. For
most people, listening or playing music is a pleasurable
experience that may evoke a memory or emotion. Advances
in technology have improved our access to all kinds of
music, with many people now downloading and sharing
digitized music files and using portable devices to play and
store large collections of music.
Although the environmental link between photosensitivity
and epilepsy is well known, the interaction between music
and epilepsy is less well perceived or understood. It appears
some patients with seizures might gain benefit from musical
exposure, whereas other patients may experience an exacer-
bation of their seizures. The dichotomous effect of music on
epilepsy is an intriguing yet poorly understood phenomenon
and the subject of ongoing research and debate. In addition,
the effects of medications and surgical procedures used in
Accepted April 3, 2012; Early View publication March 21, 2012.
Address correspondence to Melissa Maguire, Consultant Neurologist,
Leeds General Infirmary, Great George Street, Leeds, West Yorkshire LS1
3EX, U.K. E-mail: maguirem@doctors.org.uk
Wiley Periodicals, Inc.
ª 2012 International League Against Epilepsy
947
minergic system modulation and the ambivalent action of
cognitive and sensory input in ictogenesis may provide
possible theories for the dichotomous proconvulsant and
anticonvulsant role of music in epilepsy. The effect of
antiepileptic drugs and surgery on musicality should not
be underestimated. Altered pitch perception in relation
to carbamazepine is rare, but health care professionals
should discuss this risk or consider alternative medication
particularly if the patient is a professional musician or
native-born Japanese. Studies observing the effect of epi-
lepsy surgery on musicality suggest a risk with right tem-
poral lobectomy, although the extent of this risk and
correlation to size and area of resection need further
delineation. This potential risk may bring into question
whether tests on musical perception and memory should
form part of the preoperative neuropsychological workup
for patients embarking on surgery, particularly that of the
right temporal lobe.
KEY WORDS: Musicogenic, Therapy, Carbamazepine,
Temporal lobectomy.
epilepsy may have the potential to alter a patient’s musical-
ity, which could have disastrous consequences.
This review aims to summarize the current body of evi-
dence on music and its association with epilepsy. It outlines
our current understanding of musical processing in the
human brain, and how this process could be disrupted in the
production and propagation of seizures. Also discussed are
ictal musical phenomena, music therapy in refractory epi-
lepsy, and the effect of antiepileptic medication and epi-
lepsy surgery on musicality.
Musical Processing and the
Human Brain
The relation between music and the brain has been exten-
sively researched over the past century, from the authorita-
tive work published by Critchley and Henson (1977) titled
‘‘Music and the Brain’’ to a modern update of the literature
from intervening decades by Stewart et al. (2006).
During the late 19th century, German researchers pub-
lished numerous studies analyzing the disturbance of musical
functioning in patients with brain damage, observing how
focal lesions affect musical activities. In 1888, Knoblauch
948
M. J. Maguire
introduced the term ‘‘amusia’’ meaning impaired musical
capabilities. He described a sensory (receptive) amusia
whereby affected patients cannot hear, read, or understand
music, and motor (expressive) amusia whereby patients
have an inability to sing, write, or play music (Knoblauch,
1888). Several other authors explored lesional conse-
quences on music perception (Head, 1926; Kleist, 1962;
Luria et al., 1965), and a plethora of interesting discoveries
were made. Although many cases of amusia were related to
an abnormality within the right temporal lobe, this was by
no means true in all reported cases and some lesions lateral-
ized to the left hemisphere. Thalamic lesions in association
with a hemiparesis were reported to cause a peculiar alter-
ation in musical perception on the affected side. One patient
seemed unable to tolerate hymns in church on his affected
side, causing him to rub the affected hand (Head, 1920).
Although these studies provided some evidence on the ana-
tomic components of musical perception, the cases were
confined to patients with damaged brains, and it is possible
that the underlying pathologic process may have affected
the results.
Our modern understanding of the mechanisms involved
in musical processing has been aided by advances in func-
tional imaging studies, using positron emission tomography
(PET) and functional magnetic resonance imaging (fMRI)
techniques. These techniques display the changes in hemo-
dynamic response to mean synaptic firing rates in the brain,
and have allowed researchers to delineate the anatomic
areas pertinent to the processing of music. Electroencepha-
lography (EEG) and magnetoencephalography (MEG) stud-
ies have also been employed to record postsynaptic
potentials during listening to music. Recent studies have
also identified the structural and functional organization of
the brain in musicians.
Musical processing encompasses brain mechanisms in
musical perception, recognition, and emotion. Musical per-
ception requires the decoding of a musical stimulus within
the primary auditory cortex in Heschl’s gyrus and the associ-
ation cortex in the superior temporal gyrus (planum tempo-
rale). The primary auditory cortex is thought to receive
thalamic afferents from the medial geniculate nucleus,
which in turn connect through networks to the association
cortex, mesolimbic systems, and other multisensory cortices
(Stewart et al., 2006). The primary auditory cortex appears
especially sensitive to tone, whereas the auditory associa-
tion cortex is thought to perceive pitch (Penagos et al.,
2004) and perform more complex musical processing tasks
relating to linear stimuli, for example, melodies (Liegeois-
Chauvel et al., 1998) and nonlinear stimuli, for example,
chords and consonances. Similar areas within the secondary
auditory cortex are also activated in speech (Price et al.,
2005). The perception of rhythms, with no particular melo-
dic content, is thought to involve activation of the cerebel-
lum and basal ganglia as well as the superior temporal
lobes, suggesting a motor aspect to rhythm perception.
Epilepsia, 53(6):947–961, 2012
doi: 10.1111/j.1528-1167.2012.03523.x
Musical recognition and emotion are thought to involve
orbitofrontal areas and the limbic system, which may
serve to store past auditory memory and emotional evalu-
ation of a musical stimulus (Dellacherie et al., 2009). For
example, chord dissonance per se may be detected via the
auditory association cortex, but the evoked unpleasant
emotional response appears to be mediated via limbic
structures.
An extensive review by Stewart et al. (2006)) analyzed
38 case reports and 27 case series reporting on symptom-
atic musical listening deficits, with associated structural
imaging findings. The authors summarized anatomic areas
that are pertinent to pitch processing, temporal processing,
musical memory, and emotional responses to music using
five cartoons. Anatomic areas implicated in 50% or more
of the studies for a particular function were mapped out
using colored dots, with the size of the dot representing
the proportion of studies (Fig. 1). The review ascertained
that the anatomic areas implicated in musical listening
deficits were central, affecting a number of regions
beyond Heschl’s gyrus, with right-sided predominance.
Half of cases were associated with coexisting problems of
speech perception.
Determinants of musicality have also been explored over
the years by examining environmental and genetic factors.
Musicality is likely to be a polygenic trait and dependent on
home environment and parental attitudes to the develop-
ment of musical talent in children.
Studies have also identified structural differences in the
brains of musicians versus nonmusicians in a number of
anatomic areas including auditory (Schneider et al.,
2002), motor (Amunts et al., 1997), somatosensory, supe-
rior parietal (Gaser & Schlaug, 2003), callosal (Schlaug
et al., 1995), and cerebellar (Hutchinson et al., 2003)
areas. The larger size of the corpus callosum in musicians
may indicate increased cross-communication between
both sides of the brain, merging spatial-emotional process-
ing of the right brain with linguistic analytical processing
of the left brain. People with absolute pitch engage left
dorsofrontal regions, whereas those lacking absolute pitch
appear to have a so-called working memory for pitch
located within inferior frontal areas. The age of onset of
musical training, that is, younger than 4 years old, appears
to be a key predictor of absolute pitch, suggesting that this
ability develops during a critical period for imprinting
(Sergeant & Roche, 1973).
Music and Epilepsy
It is possible that brain mechanisms involved in musical
processing may be involved in the generation and propaga-
tion of seizures, manifesting with musical semiology.
Hyperexcitable cortical areas may also become sensitized
to specific musical triggers and may explain the basis of
musicogenic epilepsy.
 949
Music and Epilepsy

Figure 1.
Critical brain substrates for musical
listening disorders according to
pitch processing, temporal process-
ing, musical memory, and emotional
responses to music. The presence
of a colored circle corresponding to
a particular function in a region indi-
cates that at least 50% of studies of
the function implicate that region.
The size of each circle is scaled
according to the proportion of stud-
ies of the function implicating that
region. Meter is not represented, as
no brain area was implicated in 50%
or more of cases. amyg, amygdala;
aSTG, anterior superior-temporal
gyrus; bg, basal ganglia; cc, corpus
callosum; fr, frontal; hc, hippocam-
pal; HG, Heschl’s gyrus; ic, inferior
colliculi; i, inferior; ins, insula;
l, lateral; m, medial; thal, thalamus;
PT, planum temporale; TG, tempo-
ral gyrus. Reprinted from Stewart
et al. (2006) with permission from
Oxford Journals.
Epilepsia ILAE

Musicogenic epilepsy has an estimated prevalence of one

Musicogenic epilepsy
Musicogenic epilepsy was first coined by Critchley,
1937, who described a rare form of epilepsy in which
seizures, typically simple or complex partial types, are
triggered by music. However, descriptions of possible
music-induced seizures had been reported in the literature
as early as 1841. The Chinese poet Jichin Kyo, quoted by
Fujinawa et al. (1977) stated:
Since my remote boyhood I have always been absent
minded while hearing the sound of a street vendor’s flute.
I fall sick when I hear the sound of the flute in the evening
sun, although I do not know the reason.
case per 10,000,000 population. It is classified as a rare form
of complex reflex epilepsy by the International League
Against Epilepsy (ILAE) (Berg et al., 2010), with seizures
induced by listening to music in most cases, but playing,
thinking, or dreaming of music have all been cited. In
reported cases, seizures following a musical stimulus can
often be delayed by several minutes. During this latent per-
iod, patients may experience distress, agitation, tachycardia,
and rapid breathing building up to the seizure, although this
is inconsistently reported. The seizures may not all be exclu-
sively stimulated by music, and there is reported variability
in the form of musical stimulus. For example some patients

Epilepsia, 53(6):947–961, 2012

doi: 10.1111/j.1528-1167.2012.03523.x
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M. J. Maguire
report seizures according to type (jazz, classical, choral,
popular), instrument (organ, flute, piano), emotional content
of the music (sad, sentimental, upbeat), or even composer
(Wagner, Beethoven, Beatles). Some patients have also
found strategies that enable them to abort a seizure. These
features have led one author to question whether musico-
genic epilepsy is a true form of reflex epilepsy (Vizioli,
1989).
In many cases, however, the seizure has been reported to
occur within seconds and following a very specific stimulus,
for example church bells (Poskanzer et al., 1962) or the
melody of the Marseillaise (Vercelletto, 1953). Other
reports cite the incorrect positioning of the larynx leading to
a husky or ‘‘metallic’’ quality to singing causing seizures
(Brien & Murray, 1984), whereas others cite cognitive pro-
cessing (Ogunyemi & Breen, 1993), playing a certain hymn
(Sutherling et al., 1980), or improvisation (Le Chevalier
et al., 1985) as triggering events.
A recent review reported on 110 cases of music-evoked
seizures published between 1884 and 2007 (Pittau et al.,
2008). The mean age of onset of musicogenic seizures was
28 years, with a female predominance. Patients more often
than not had high musicality. Seizures induced exclusively
by music occurred in 34 patients, with the majority also
reporting spontaneous seizures. Autonomic auras were
common with oroalimentary automatisms occurring in more
than one fourth of cases. In 60 patients with ictal electroen-
cephalography (EEG), the focus of activity localized to the
temporal lobe with right-sided predominance. Ictal single
photon emission computed tomography (SPECT) in six
cases demonstrated abnormalities within the right temporal
lobe involving mesial structures in four and within the left
temporal lobe in two cases. The musical stimulus varied
greatly, with a small proportion identifying certain tones or
sounds causing seizures and others reporting that any form
of music triggered events. The review also reported an fMRI
study on a patient with typical music-induced seizures
played ‘‘neutral’’ music and ‘‘emotionally charged melody’’
music. It revealed that during the playing of neutral music,
only acoustic areas were highlighted, but during emotional
melodies, the activity also involved frontooccipital areas.
This broadly correlates with findings by Mrocz et al.
(2003), who demonstrated early activation of the right
frontoorbital area prior to seizure activity from the left tem-
poral lobe. However, Mrocz et al. (2003) suggested that
activity provided evidence of emotional arousal and mem-
ory related to the music rather than to seizure activity per se,
whereas in the review, frontal cortical activity was thought
to represent the beginning of paroxysmal discharges unde-
tected by scalp EEG.
Invasive monitoring of seizure propagation in musico-
genic seizures has been reported in three studies. Subdural
recordings from one patient revealed cortical dysplasia
within the superior temporal gyrus (Trevathan et al., 1999).
One study using a subdural grid showed foci in the right lat-
Epilepsia, 53(6):947–961, 2012
doi: 10.1111/j.1528-1167.2012.03523.x
eral temporal lobe, right mesial temporal lobe, and bilateral
temporal lobes (Tayah et al., 2006). A third study used flu-
orodeoxyglucose (FDG)–PET with invasive techniques
(subdural grid and depth electrodes) and identified a focus
within the right mesial temporal lobe with propagation to
the lateral temporal cortex, Heschl’s gyrus, insula, and fron-
tal lobes (Mehta et al., 2009).
These clinical studies suggest an affective role in musico-
genic seizures, as evidenced by mesial temporal activity.
Authors speculate that emotion triggered by music is the
causal factor rather than the auditory content of the music
per se. Merely thinking about music has been reported as a
trigger, suggesting the importance of musical memory and
emotion.
Responses to limbic stimulation in subjects with epilepsy
are thought to depend on widespread neuronal matrices
linked through connections that have become strengthened
through repeated use (Gloor, 1990). This is of interest given
that the onset of seizures often predates the sensitivity to
music.
However, the imaging studies provide less obvious clues
as to why a subset of patients may develop seizures on expo-
sure to a simple sound or tone, where there may be a less
obvious emotional component (Wieser et al., 1997). In
addition, musicogenic seizures have since been reported in
children as young as 6 months old (Lin et al., 2003), sug-
gesting musicogenic seizures are likely to be epileptiform
and not functional in nature.
Treatment of musicogenic seizures usually comprises
avoidance of the musical triggers together with antiepileptic
medication. In the past, various behavioral therapies have
been tried in patients with high emotional states. Joynt et al.
(1962) suggested the use of sensory extinction, by playing
innocuous music or small snatches of noxious music prior to
playing the seizure-producing music, the idea being that
cells typically initiating seizure activity would be set into
activity by similar combinations of tones and chords, ren-
dering them less susceptible to the actual seizure-triggering
melody. Thereby, excitable nerve cells are ‘‘usurped’’ by a
competing stimulus. Other methods of psychotherapy and
deconditioning techniques have been used as treatment in
musicogenic epilepsy patients (Daly & Barry, 1957; Forster
et al., 1965).
At present the exact pathophysiology of musicogenic sei-
zures is undetermined. Questions around what make a cer-
tain type or facet of music epileptogenic to a particular
person remain unanswered, but it is possible that hyperex-
citable cortical areas could be stimulated to different
degrees and extents by different musical stimuli. These
questions remain an intriguing subject of ongoing research.
Musical ictal phenomena
Music may manifest as part of ictal semiology in associa-
tion with temporal lobe epilepsy. The phenomena could
be either positive, as in musical auditory hallucinations,

musicophilia, ictal singing or whistling, or negative as in
ictal aprosody and amusia.
Musical hallucinations
Some patients may develop musical auditory hallucina-
tions as part of temporal lobe epilepsy. In comparison to
musicogenic epilepsy, there is a less clear association with
high musicality, and the emotional associates of temporal
lobe attacks with musical components are varied including
anger, fear, and panic. In a cohort of 666 patients with tem-
poral lobe epilepsy, around 16% had auditory hallucinations
that took the form of sounds such as ticking or banging or
more complex forms such as a specific melody or orchestral
piece (Currie et al., 1971). These seizures were associated
with activation of the superior temporal gyrus with right-
sided predominance. In addition, some patients who experi-
enced voices rather than music as a feature of their seizures
had stimulation within the same cortical regions as those
triggered by a musical stimulus. More recent research in
subjects with musical hallucinations implicated an autono-
mous network of nonprimary auditory areas in generating
abnormal neural activity that sustains musical hallucina-
tions (Griffiths, 2000).
Musicophilia
Musicophilia or musical craving is an extremely rare phe-
nomenon. It has been reported in a patient with a stroke
causing damage to the left hemisphere (Jacome, 1984) and
also in frontotemporal dementia (Boeve & Geda, 2001).
Rohrer et al. (2006) described an interesting case of a
65-year-old woman with right-sided temporal lobe epilepsy
who developed musical craving following commencement
of lamotrigine for complex partial seizures. Before intro-
duction of treatment she had been indifferent to music,
avoiding music where possible and never attending con-
certs. She had no musical training. Within weeks of treat-
ment she was actively listening to classical music stations
for several hours a day, and demanding to attend musical
concerts. She described listening to music as an intensely
pleasurable and highly emotional experience. There were
no other changes to her behavior or personality.
In this case the musicophilia was driven by the pleasur-
able emotional response derived from the music. The
authors speculated that emotional responses to music
might have been altered by functional reorganization of
neocorticolimbic interactions as a consequence of long-
standing seizures. Treatment might enhance these altered
emotional responses by restoring flow within the reorga-
nized sensory-limbic networks. This theory relates to the
described phenomenon of ‘‘forced normalization,’’
whereby patients may develop behavioral changes, for
example depression in the context of improved seizure
control. This is thought to occur due to electrophysiologic
and neurochemical alterations involving limbic circuitry
(Krishnamoorthy et al., 2002).
951
Music and Epilepsy
There have been other fascinating accounts of patients
reporting musicophilia and musical inspiration in associa-
tion with altered emotional perception: following electrocu-
tion by lightning and following surgery for a right temporal
oligodendroglioma (Sacks, 2008). The underlying neural
mechanisms of musicophilia in these cases remain unex-
plained.
Ictal singing, humming, and whistling
The act of singing involves multiple cortical areas includ-
ing left superior temporal and parietal regions as well as
both left and right premotor cortex, anterior superior tempo-
ral gyrus, and planum polare (Callan et al., 2006).
Singing as an ictal phenomena is rare. There have been
nine cases of ictal singing reported in the literature (Enatsu
et al., 2011). Four had frontal lobe epilepsy, three had tem-
poral lobe epilepsy, and in two cases the epileptogenic zone
could not be localized. There has also been variability as to
whether the ictal focus emanates from a dominant or non-
dominant focus. In one case the authors were able to distin-
guish different localizations depending on whether the
patient was humming or singing. Humming appeared to
occur due to a temporal focus, whereas singing occurred
due to a focus within the frontal lobe, specifically within the
right prefrontal cortex (Bartolomei et al., 2007).
Authors have speculated that ictal singing is a form of
automatism that occurs either from a release phenomenon,
or by activation of learned motor patterns or memories
(Meierkord & Shorvon, 1991). Because the action of sing-
ing involves multiple regions, it suggests that ictal singing
may occur through recruitment of a propagation network
mimicking musical action via numerous cortical areas,
rather than it occurring via a specific cortical focus.
There have been five cases of ictal whistling reported
within the literature. (Lazzarino & Valassi, 1982; Tan et al.,
1990; Loring et al., 1994; Raghavendra et al., 2010). Later-
alization has not been consistent among cases. One report
suggested a frontal focus, whereas the remaining cases
reported this rare automatism with temporal lobe epilepsy.
In two cases, ictal whistling was abolished by temporal lobe
surgery. The act of whistling requires the utilization of
perioral, oral, and respiratory muscles and the recruitment
of a complex neuronal network. Functional imaging has
demonstrated multiple areas involved in whistling including
inferior rolandic cortex, cingulate cortex, basal ganglia,
amygdala, thalamus, and cerebellum (Dresel et al., 2005).
Ictal aprosody and amusia
Disorders of prosody refer to abnormalities in the affec-
tive components of speech including intonation, melody,
pitch, and gestures. This abnormality is considered either
expressive or receptive and may occur due to lesions in the
nondominant hemisphere. Amusia, as described previously,
and aprosody are considered to be negative phenomena
often occurring as a result of stroke. However, there has
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M. J. Maguire
been one reported case of expressive amusia and aprosody
manifesting as an ictal feature of seizures emanating from a
right temporooccipital lobe focus (Bautista & Ciampetti,
2003). On commencing antiepileptic treatment, the clinical
events ceased and the patient’s musical capabilities were
restored. Negative ictal phenomena are poorly understood
and can include ictal blindness, paralysis, speech arrest, and
loss of hearing. They are thought to occur either via stimula-
tion of inhibitory cortical regions, dampening of receptive
abilities of sensory regions, or inhibition of spinal motor
neurons.
Music Therapy for Epilepsy
The therapeutic potential of music has largely been
explored in cognitive science. The cognitive effects of
music are well documented in the literature, although these
effects have been subject to scrutiny. Rauscher et al. (1993)
observed an immediate enhancement in spatial-temporal
reasoning in college students exposed to 10 minutes of the
Mozart Sonata K448 (Rauscher et al., 1993). The authors
subsequently coined the term the ‘‘Mozart effect.’’ Further
studies in Parkinson’s disease, senile dementia, and atten-
tion-deficit/hyperactivity disorder also described cognitive
benefits from listening to music (Pacchetti et al., 2000;
Foster & Valentine, 2001; Rickson & Watkins, 2003;
Turner, 2004).
Rauscher et al. went on to devise an animal model of the
‘‘Mozart effect’’ and demonstrated that rats exposed to long-
term Mozart in utero and also postpartum performed better
in negotiating a T maze than control rats that had been
exposed to silence, white noise, or the music of Philip Glass.
The effect lasted for at least 4 h after months of exposure
(Rauscher et al., 1998). Further studies in mice showed sim-
ilar enhanced maze skills for up to 24 h having been
exposed to 12 h of the Mozart sonata but not with mice
exposed to Beethoven (Aoun et al., 2005). Animal studies
have also shown that music exposure may enhance dendritic
branching, cell proliferation, and neurogenesis in the hippo-
campus and amygdala (Kim et al., 2006).
The reported musical effects on cognition have been
viewed with scepticism among neuroscientists. Concerns
have arisen from the lack of matched musical controls
within experiments. It could be argued that Hayden is a
better musical match to Mozart in terms of structure than
Beethoven or Glass. In addition, the short duration of effect
and difficulty in controlling for affective responses to music
in experiments has attracted criticism.
The evidence for music as an anticonvulsant in human
epilepsy is limited as is our understanding of the brain mech-
anisms involved. The clinical evidence is confined mainly
to Mozart music and in Taiwanese children with generalized
seizures. Two small studies by the same author reported on
the effect of Mozart K448 on epileptiform discharges and
seizure frequencies in Taiwanese children. The first study
Epilepsia, 53(6):947–961, 2012
doi: 10.1111/j.1528-1167.2012.03523.x
included 58 Taiwanese children with partial epilepsy.
Continuous EEG monitoring occurred before, during, and
after eight minutes of exposure to the Sonata. In 81% of
patients there was a reduction in interictal discharges by an
average of 33%, with the greatest reduction in those patients
with generalized discharges. However, around 20% showed
an increase in interictal discharges by an average of 14%.
No significant differences were found according to gender,
IQ, or number of antiepileptic drugs and response to music.
The reduction in interictal discharges was not dependent on
the level of alertness or specific emotional response (Lin
et al., 2010). The second study included 11 Taiwanese
children aged 2–14 years old with refractory epilepsy. Two-
thirds had generalized seizures of symptomatic causes, and
the majority (70%) had learning difficulties. Seizure fre-
quency was observed for 6 months before music and during
6 months of Mozart K448 exposure. The study found that
73% of patients had a 50% or greater reduction in their sei-
zure frequency, with two patients becoming seizure free
during exposure to music. There were no significant
differences in response status according to seizure type, IQ,
etiology, or gender (Lin et al., 2011).
There have also been reports of a reduction in interictal
discharges when exposed to Mozart K448 in patients with
rolandic types of seizures (Turner, 2004). Reductions in
ictal spiking have been reported in subjects in coma and
refractory nonconvulsive status following exposure to
Mozart Sonata K448 (Hughes et al., 1998; Lahiri &
Duncan, 2007; Kuester et al., 2010), and Johann Sebastian
Bach (Miranda et al., 2010). Authors suggest a direct corti-
cal response to Mozart as opposed to responses relying on
emotion or level of awareness.
Neuroscientists have also published on possible theories
for the anticonvulsant effect of music. Hughes et al. (1998)
discussed the Trion model and that exposure to a highly pat-
terned or superorganized stimulus (in space and time) may
lead to learning of innate memory patterns, which in turn
may decrease the excitability of an epileptogenic focus.
Other authors have implicated mirror neurons in mediat-
ing the anticonvulsant effect. Mirror neurons discharge or
are modified when an individual is performing an action
while exposed to musical or visual stimulation (Molnar-
Szakacs & Overy, 2006). Musical activities, such as dancing
to music, playing musical instruments, and moving mouths
and larynxes to sing are examples in which music and motor
functioning are connected. Authors speculate that mirror
neurons mediate neuronal activity by linking auditory stim-
ulation directly to the motor cortex. Motor system modula-
tion in transcranial magnetic stimulation and in behavioral
studies has been observed to change during auditory stimu-
lation (Buccino et al., 2005).
A further theory proposes modification of the dopamine
neurotransmitter pathways in the effect of Mozart K.448 on
epilepsy. Exposure to music is known to increase the
expression of dopamine in the brain (Sutoo & Akiyama,

2004). In recent years, dopamine has been reported to have
an important role in the pathophysiology of epilepsy. The
reduced binding capacity of dopamine receptors in the basal
ganglia has been hypothesized to contribute to seizures
in autosomal dominant frontal lobe epilepsy (ADNFLE)
(Fedi et al., 2008) and juvenile myoclonic epilepsy (JME)
(Landvogt et al., 2010). An FDG-PET study in seven
patients with mesial temporal lobe epilepsy identified
reduced D2/D3 receptor binding (Werhahn et al., 2006). In
a study in animals, pilocarpine-induced seizures altered the
binding capacity of dopaminergic receptors in striatal and
hippocampal areas, and facilitated the propagation and
maintenance of seizures (Mendes de Freitas et al., 2005). It
is possible that listening to music modifies dopaminergic
pathways within subcortical structures to influence tha-
lamocortical projections.
In summary, further research is needed to explore the
potential anticonvulsant role of music both at the basic sci-
ence and clinical level. The research to date has focused
principally on Mozart music without a good understanding
of the basic science behind the effect. There is limited evi-
dence of an effect with Mozart on seizures in the clinical set-
ting. It may be that some aspects of musical stimuli will
ultimately prove to have therapeutic potential, but for the
moment these remain largely unknown and unproven and
our understanding of the brain mechanisms involved are
limited.
Mechanisms for the Proconvulsant
and Anticonvulsant Effects of
Music in Epilepsy
To evaluate the therapeutic potential of music we need
to try and understand why music might behave as anticon-
vulsant in some patients with epilepsy yet proconvulsant
in others. Understanding why this paradox occurs may be
explained through the dichotomous effect of dopamine on
receptors in the brain. Previous studies have shown that
the anticonvulsant action of dopamine has been attributed
to D2 receptor stimulation in the forebrain, whereas selec-
tive D1 receptor activation appears to lower the seizure
threshold both clinically and in animal models (Al-Tajir &
Starr, 1990; Starr, 1996). Studies in mesial temporal lobe
epilepsy have identified reduced D2/D3 binding capacity
in the striatum. This may be a consequence of receptor
downregulation, due to ongoing seizures (Starr, 1996).
Striatal dopamine receptor downregulation might disin-
hibit thalamocortical connections by means of inhibition
of the substantia nigra, thereby further enhancing cortical
hyperexcitability. This has been explored in animal mod-
els of absence epilepsy (Deransart et al., 2000) A further
study has ascertained that signaling through D2 receptors
could play a neuroprotective role against pathologies
involving glutamate-induced neurodegeneration (Bozzi
953
Music and Epilepsy
et al., 2000). Playing music may promote dopamine
release thereby flooding the dopaminergic systems and
upregulating D2 receptors. In patients with temporal lobe
epilepsy, dopamine flooding may potentially behave in an
anticonvulsant way through D2 receptor activation. In
musicogenic epilepsy, it is possible that the emotional
effect of the musical trigger could lead to increased dopa-
mine within the medial prefrontal cortex (PFC) (Kaneyuki
et al., 1991). This increase in dopaminergic activity within
the PFC could in turn suppress the limbic dopaminergic
response and result in the propagation of seizures. The
limbic-PFC circuit has also been implicated in an animal
model of anxiety (Bishop, 2007). This is interesting given
that anxiety correlates with a lack of seizure control in
JME, and a risk of >20 lifetime generalized tonic–clonic
seizures (De Araujo Filho et al., 2006). Further research is
needed into the role of dopamine pathways in epilepsy
and the interaction with music.
Another interesting area of research is the ambivalent
action of sensory and cognitive input in ictogenesis. This is
relevant to understanding the effect of music in epilepsy
given that limbic and multisensory cortices are involved in
musical processing.
A study by Guaranha et al. (2009) observed the effect
of cognitive tasks on epileptiform discharges in 76
patients, aged 12–53 years old with JME. The study used
a video-EEG protocol recording brain activity during
action programming tasks, for example, spatial construc-
tion, and thinking tasks, for example, mental calculation.
The recording was performed over 4–6 h, and EEG dis-
charge rates during specific tasks were compared to a
baseline awake EEG recording. The study observed a pro-
vocative effect on discharges during cognitive tasks in 29
patients and an inhibitory effect in 28 patients. In 30
patients there was no effect on discharges during cogni-
tive tasks. Action programming tasks, particularly manual
praxis, were the most provocative, whereas thinking tasks,
in particular mental calculation, were the most inhibitory.
The effect of cognitive tasks on epileptiform discharges
appeared independent of drug treatment, seizure control,
or age of patient. These findings broadly correlate with
other studies (Matsuoka et al., 2002; Matsuoka et al.,
2005). The authors speculated that cognitive tasks recruit-
ing motor pathways were more epileptogenic, whereas
spatial thinking involving activation of parietal regions
without motor recruitment may act to dampen activity in
neighboring motor cortices and thus seizure activity.
Music may act as anticonvulsant by activating and
enhancing areas of cortex involved in spatial cognitive
processes that produce greater inhibition, either directly
on surrounding motor areas or via inhibitory corticotha-
lamic feedback loops. Similarly music may act as procon-
vulsant in musicogenic epilepsy where anticipation of
music and memory responses may enhance activity in the
Epilepsia, 53(6):947–961, 2012
doi: 10.1111/j.1528-1167.2012.03523.x
954
M. J. Maguire
PFC and associated frontostriatal connections (Leaver
et al., 2009).
The Effect of Antiepileptic
Therapies on Musicality
Music exposure may thus influence seizures, but the
treatment of seizures may affect musicality. This could have
potentially disastrous effects, particularly if the patient
relies on his or her musical skills for employment.
Antiepileptic drugs
Carbamazepine has been associated with a reversible
disturbance of pitch perception. Since 1993, there have
been 26 reported cases of this adverse effect reported in
the literature (Tateno et al., 2006). Of interest is that all
but one case have involved Japanese patients. Patients
were aged between 4 and 42 years old with a mean age of
19 years and most were female. Twenty of 26 patients
were prescribed carbamazepine for epilepsy. Symptoms of
altered pitch perception seem to develop 2 h to 2 weeks
after the administration of carbamazepine. On reduction
in dose or discontinuation of carbamazepine, the abnor-
mality appeared to fully reverse. Patients perceived a
lower pitch than usual and in the majority of cases by a
semitone. Many of the patients were musical and had
studied an instrument.
The mechanism of pitch disturbance with carbamaze-
pine is unknown. Authors speculate that carbamazepine
acts at a local level, either by changing the mechanics of
the organ of Corti (Chaloupka et al., 1994), or by affect-
ing the sarcolemma of the stapedius muscle and altering
the tension on the tympanic membrane receiving sound.
Alternatively carbamazepine may act at a central level.
Carbamazepine-treated patients have been found to have
prolonged I–III and I–V latencies of the auditory brain-
stem response (Medaglini et al., 1988). However, auditory
brainstem responses in patients with abnormal pitch per-
ception have been reported to be normal. Acoustic effects
of lamotrigine in pediatric patients with epilepsy have
been assessed in a recent study. The authors examined
speaking rate, pitch, and articulation rate, finding no evi-
dence of adverse effect with lamotrigine (Yun et al.,
2011).There have not been any reports of studies on other
antiepileptic drugs and effect on musicality.
Temporal lobe surgery
The effect of temporal lobe surgery for intractable epi-
lepsy on musical processing is an important issue and the
consequences for patients could be devastating. Tables 1
and 2 highlight published studies examining the effect of
temporal lobe surgery on musical emotion, recognition, and
perception. Most of these studies have involved small num-
bers of surgical patients, and the methods used for assessing
musical processing have varied considerably.
Epilepsia, 53(6):947–961, 2012
doi: 10.1111/j.1528-1167.2012.03523.x
Studies investigating the effect of surgery on musical
emotion report conflicting results. Some studies report
impaired recognition of scary music following anterome-
dial temporal lobe resection (Khalfa et al., 2008; Gosselin
et al., 2011), whereas another study found that patients
who underwent unilateral medial temporal lobe surgery
were able to judge emotional dissimilarities in music as
well as healthy participants (Dellacherie et al., 2011).
These discrepancies may relate to the amount of surgical
resection, the methodologic differences in assessing emo-
tional responses, or the cognitive processes underlying the
emotional responses.
Studies examining musical recognition broadly agree
and report impairment in recognizing previously pre-
sented tunes following temporal lobe surgery but with a
right-sided predominance (Shankweiler, 1966; Samson &
Zatorre, 1991, 1992). The outcomes suggest a bitemporal
role in musical recognition and possibly for emotion as
well.
Studies examining pitch processing report impairments
in pitch direction, pitch pattern, timbre, and tonal structure
in patients who have undergone right temporal lobectomy
including Heschl’s gyrus (Milner, 1962; Zatorre, 1985;
Samson & Zatorre, 1988; Zatorre, 1988; Zatorre & Samson,
1991; Kester et al., 1991; Zatorre & Halpern, 1993; Samson
& Zatorre, 1994; Johnsrude et al., 2000; Warrier & Zatorre,
2004). Similarly, studies exploring the effect on rhythm and
time intervals show impairment in patients who have under-
gone right temporal lobectomy, including the superior tem-
poral gyrus (Milner, 1962; Liegeois-Chauvel et al., 1998).
It appears that patients undergoing right temporal lobec-
tomy are more at risk than those undergoing left temporal
lobectomy in acquiring postoperative problems with musi-
cal perception.
Preoperative and Postoperative
Evaluation of Musical Functioning
in Patients with Epilepsy
Published studies suggest a bitemporal role for musical
recognition and possibly emotion, but a right temporal role
for musical perception. The potential risks to musical pro-
cessing should be discussed with patients, particularly those
undergoing right temporal lobectomy. It would be interest-
ing to ascertain current practices in discussing musical
implications in neurosurgical clinics.
Preoperative neuropsychological evaluation of musical
processing should also be considered in temporal lobe resec-
tive patients. There have been many tests devised over the
years, the detail of which is beyond the scope of this review.
However, two internationally recognized assessment tools
are mentioned briefly here.
The Seashore Measures of Musical Talent was a musical
aptitude test developed in 1919 and modified in 1960 to
 Table 1. Summary of studies investigating the effect of temporal lobe surgery for refractory epilepsy on musical emotion and recognition
Author and year Resection No Age, years (gender) Musical education Test Key finding
Musical emotion
Dellacherie et al. (2011) Controls (C) 12 36 (m) All groups had limited or no Multidimensional scaling No difference in ability to assess
Medial temporal, sparing STG (L) 10 38 (m) formal musical training analysis on emotional emotional dissimilarity in
Medial temporal, sparing STG (R) 9 37 (m) dissimilarity resection groups versus (C)
Gosselin (2005) Controls (C) 16 27–47 Patient group: None Emotional task Impaired rating of fearful music in
Medial temporal, sparing STG (L) 8 20–60 Control group: Some 5 years Error detection task both patient groups. Ability to
Medial temporal, sparing STG (R) 8 20–60 training recognize happy and sad music
not impaired
Khalfa et al. (2008) Controls (C) 60 32 (m) 30% control group and Musical excerpts Impaired sadness recognition and
Anterior temporal including STG 12 29 (m) 50–60% of patient groups from Montreal Battery of dissonance in both resection
(L) with 5 years musical training Evaluation of Amusia groups versus (C)
Anterior temporal including STG 14 34 (m) Impaired happiness recognition in
(R) (L) versus (R) and (C)
Musical recognition
Samson and Zatorre (1991) Controls (C) 20 31 (m) 30% of each group with Song excerpts Impaired recognition of
(Experiment 1) Anterior temporal (including HG) 22 27 (m) musical training (Serafine et al., 1984) previously presented tunes in
(L) patient groups
Anterior temporal (including HG) 21 30 (m)
(R)
Samson and Zatorre Controls (C) 10 28 (m) Unknown Song excerpts Impaired recognition of
(1991) Anterior temporal (including HG) 12 30 (m) (Serafine et al., 1984) previously presented tunes
(Experiment 2) (L) without lyrics in (R) group
Anterior temporal (including HG) 12 29 (m)
(R)
Samson and Zatorre (1992) Controls (C) 15 28 (m) 10% of each group with 112 melodic patterns Impaired recognition in
Anterior temporal (including HG) 20 30 (m) musical training determining which tune had
(L) previously been presented in
Anterior temporal (including HG) 20 30 (m) both patient groups compared
(R) to (C)
Shankweiler (1966) Controls (C) 20 – Unknown Dichotic presentation of Impaired recognition of
Anterior temporal (including HG) 20 – tunes pre- and postsurgery previously presented tunes
(L) postsurgery for (R) group versus
Anterior temporal (including HG) 20 – (C) and (L)
(R)
M, mean value; STG, superior temporal gyrus; HG, Heschl’s gyrus; R, right; L, left; C, controls.
Music and Epilepsy

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Epilepsia, 53(6):947–961, 2012
955
 956

Table 2. Summary of studies investigating the effect of temporal lobe surgery for epilepsy on musical perception
Author and Year Resection No Age (years) Musical education Test Key finding
Musical perception
Johnsrude et al. (2000) Controls (C) 14 22–52 Unknown Pitch discrimination and Impaired pitch direction task in right
M. J. Maguire

Anterior temporal sparing HG (L) 12 22–53 direction tasks temporal resection including HG group
Anterior temporal sparing HG 5 22–53
(R)

Epilepsia, 53(6):947–961, 2012

Anterior temporal including HG 6 22–53
(L)
Anterior temporal including HG 8 22–53

doi: 10.1111/j.1528-1167.2012.03523.x
(R)
Kester et al. (1991) Controls (C) 12 27 (m) 100% of study participants Musical aptitude profile Pitch pattern and meter impaired in right
Anterior temporal, sparing HG 9 27 (m) <1 year of training Seashore tonal memory test temporal lobectomy versus controls
(L) and left temporal lobectomy
Anterior temporal, spaing HG (R) 12 32 (m)
Koike et al. (1996) Temporal, including STG (R) 10 28 (m) Unknown Seashore Measures of Musical No impairment of any of the six subsets
Temporal, sparing STG (R) 10 28 (m) Talents in any of the resection groups
Temporal, sparing STG (L) 9 37 (m)
Liegeois-Chauvel et al. Controls (C) 24 32 (m) 10% of each group with Temporal organization task Pitch interval impaired in all resective
(1998) Temporal, sparing STG (L) 14 31 (m) musical training groups particularly posterior STG
Temporal, sparing STG (R) 19 30 (m) group versus controls
Anterior STG (L) 5 39 (m) Rhythm impaired only in posterior STG
Anterior STG (R) 8 30 (m) group
Including posterior STG (L aid R) 8 – Meter impaired in anterior STG
resections
Milner (1962) Temporal, including HG (L) 16 – Unknown Seashore Measures of Musical Pitch pattern, timbre, loudness, and time
Temporal, including HG (R) 11 – Talent pre- and postsurgery subtests impaired in (R)
Samson and Zatorre Controls (C) 20 29 (m) 25% of each group with Melodic and chord Impaired pitch pattern in right temporal
(1988) Anterior temporal including HG 28 28 (m) musical training discrimination tasks lobectomy resections including HG
(L) versus (C) and (L)
Anterior temporal including HG 26 29 (m) No difference in tonal structure versus
(R) controls in all resection groups
Frontal (R) 14 31 (m)
Frontotemporal (R) 9 25 (m)
Samson and Zatorre Controls (C) 15 26 (m) 25% of each group with 48 pairs of digtized sounds (see Impaired timbral change in tone pairs in
(1994) Anterior temporal including HG 15 28 (m) musical training paper) right temporal lobectomy group versus
(L) (C) and (L)
Anterior temporal including HG 15 30 (m)
(R)
Samson et al. (2001) Controls (C) 14 – Unknown Psychophysical task Impaired detection of temporal
Anterior temporal (L) 11 – Tempora vaidion task irregularity in familiar tunes in (L) versus
Anterior temporal (R) 11 – (see paper) (C) and (R)
Samson et al. (2002) Controls (C) 15 26 (m) 25% of each group 36 stimulus pairs played on Impared judgment in timbral dissmilarity
with musical training different timbres in pairs of melodies in both resective
groups versus (C)
Continued
 Table 2. Continued
Author and Year Resection No Age (years) Musical education Test Key finding
Anterior temporal (L) 15 28 (m)
Anterior temporal including HG 15 30 (m)
(R)
Warrier and Zatorre Controls (C) 12 36 (m) 20% of each group with See paper for methods Impaired judgment of final note tuning in
(2004) Anterior temporal including HG 18 35 (m) musical training right temporal resection group versus
(L) (C)
Anterior temporal including HG (R) 18 37 (m)
Zatorre (1985) Controls (C) 20 32 (m) Unknown Six tonal melodies altered by Impaired discrimination of pitch direction
Anterior temporal including HG 28 27 (m) contour or scale in right temporal lobectomy including
(L) HG versus (L) and (C)
Anterior temporal including HG 30 29 (m)
(R)
Zatorre (1988) Controls (C) 18 25 (m) Unknown Pairs of tones with altered Impaired discrimination of pitch direction
Anterior temporal sparing HG (L) 15 27 (m) pitch direction in right temporal lobectomy including
Anterior temporal sparing HG 15 25 (m) HG
(R)
Anterior temporal including HG (L) 16 30 (m)
Anterior temporal including HG (R) 18 31 (m)
Zatorre and Halpern Controls (C) 14 31 (m) A few participants in each Seven songs used to assess Pitch height of two lyrics within familiar
(1993) Anterior temporal (L) 14 33 (m) group with musical pitch height songs impaired in (R) versus (C)
Anterior temporal including HG 14 32 (m) training
(R)
Zatorre and Samson Controls (C) 18 27 (m) No professional musicians Pitch discrimination assessed Impaired discrimination of pitch
(1991) Anterior temporal including HG 26 28 (m) included by target tone variation and difference between two tones with
(L) distracter tones intervening distracter tones in
Anterior temporal including HG 26 29 (m) right temporal lobectomy group
(R)
Frontal (R) 13 31 (m)
Frontotemporal (R) 7 26 (m)
M, mean value; STG, superior temporal gyrus; HG, Heschl’s gyrus; R, right; L, left; C, controls.
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Epilepsia, 53(6):947–961, 2012
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M. J. Maguire
assess musical abilities in preschool children (Seashore
et al., 1960). The test consists of six measures: pitch, loud-
ness, rhythm, time, timbre, and tonal memory. The test
requires a person to compare a pair or short series of tones
produced by a beat frequency oscillator. This test is based
on the psychophysical measures of auditory perception with
little recognizable musical content and has been reported to
be sensitive to right temporal lobe dysfunction (Milner,
1962). However, the test has been criticized for being
‘‘atomistic’’ and ‘‘unmusically orientated’’ (Mursell, 1937).
Other authors have criticized its localizing value (Steinmeyer,
1984; Boone & Rausch, 1989). The tool was also used to
assess professional musicians. The musicians scored higher
on only three of the six measures compared to population
scores, suggesting the Seashore assumptions about the
requirements for high musical talent may be incorrect
(Henson & Wyke, 1984). These more recent studies cast
uncertainty on the validity of this test in the preoperative
setting.
The Montreal Battery for the Evaluation of Amusia
(Peretz et al., 2003) is a more recent test that uses musical
material as the stimulus. The test assesses melodic and tem-
poral processing of musical perception and memory via six
tests on contour, interval, scale, meter, and memory using
thirty musical phrases. The musical excerpts can be found at
http://www.brams.umontreal.ca/plab/research. The test has
a high sensitivity even on retesting at 4 months. The test
correlated well with another widely used aptitude test,
Gordon’s musical aptitude profile (Gordon, 1965). The
authors stated that the advantage of this tool over the Sea-
shore measures or Gordon’s musical aptitude profile was
that having been more recently devised it better reflected
the current concepts of musical perception and memory.
The test was more likely to pinpoint specific deficiencies in
components of musical perception compared to Gordon’s
musical aptitude profile, which was designed to assess
musical aptitude in children and tests structural components
all at once. The test better reflected melody discrimination
and ordinary musical ability compared to the Seashore mea-
sures. This tool therefore may be more suited compared to
previously devised tools in diagnostic work looking at base-
line musical functioning and evaluation of deficits. The
website above has a tool that can be used to evaluate musical
emotion. In summary this test may be more suitable in the
presurgical evaluation setting, although further work is
required in this area.
Further research is needed into the neuropsychological
consequences of temporal lobe surgery on musical process-
ing. This could be achieved by collaboration of profession-
als within the cognitive sciences and neurosurgeons
specializing in epilepsy surgery. The trend for referring
increasing numbers of refractory epilepsy patients for sur-
gery could potentially expose increasing numbers of indi-
viduals to this problem. Understanding the consequences of
surgery on musical processing is therefore paramount.
Epilepsia, 53(6):947–961, 2012
doi: 10.1111/j.1528-1167.2012.03523.x
Conclusions
The dichotomous proconvulsant and anticonvulsant role of
music in epilepsy is a fascinating and at present poorly under-
stood phenomenon. Dopaminergic system modulation may pro-
vide one possible explanation, but this theory needs further
exploration. It is clear from clinical studies that musical percep-
tion occurs via a complex network, which if recruited or hyper-
excitable may manifest as seizures. What makes a particular
sound or sequence of sounds epileptogenic may be explained by
the stimulation to varying effect of different areas involved
within the music network. Musicogenic epilepsy may be more
common than we suspect as routine EEG does not use sound in
seizure provocation, and there may be a delay in linking a partic-
ular musical trigger to seizures.
There is limited evidence of an anticonvulsant effect with
music in epilepsy. The therapeutic potential remains for the
moment largely unknown and unproven and our under-
standing of the brain mechanisms involved are very limited.
Altered pitch perception in relation to carbamazepine is
rare, but health care professionals should discuss this risk or
consider alternative medication, particularly if the patient is
a professional musician or native-born Japanese. The effect
of epilepsy surgery on musicality is a potential and signifi-
cant issue especially with right temporal lobectomy,
although the extent of this risk and any correlation to size
and area of resection need further delineation. This potential
risk may bring into question whether musical perception,
and memory testing should form part of the preoperative
neuropsychological workup for patients embarking on sur-
gery, particularly on the right temporal lobe.
Acknowledgments
I would like to thank Dr Michael Johnson, Consultant Neurologist at
Leeds General Infirmary for his kind donation of Critchley & Henson’s
Music and the Brain, a fascinating book for all who are working within the
neurologic sciences.
Disclosure
MJ Maguire has no conflict of interest to disclose. I confirm that I have
read the Journal’s position on issues involved in ethical publication and
affirm that this report is consistent with those guidelines.
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