HeadWise HeadWise: Volume 6, Issue 2 - Page 23

Anna Pace, MD Department of Neurology The Mount Sinai Hospital New York, NY A fter middle age, the incidence of migraine tends to decrease, and often the characteristics of migraine change as well. However, it is it is not uncommon for individuals over the age of 45 to experience their first migraine episode. Elderly patients who present with their first migraine attack may not even complain of a headache, but may only have symptoms similar to those of typical auras (warnings) associated with migraine. Patients who present to the emergency department with transient (short-lived) speech disturbances, weakness, numbness or tingling (paresthesias), or visual changes, may be diagnosed as having transient ischemic attacks (TIAs) (“mini- strokes”). The medical literature, however, has shown that these events may actually be migraine – a variant called “acephalgic migraine.” In 1980, a well-known Harvard neurologist, C. Miller Fisher, described 120 patients who experienced symptoms of a TIA, with or without headache, and coined the term “late-life migraine accompaniments.” These transient migraine accompaniments include visual symptoms, paresthesias (pins and needles sensations – particularly involving the hand and lips), speech disturbances, and weakness. Visual symptoms may include those similar to the visual auras commonly seen with migraine – shimmering spots, zigzag lines, black and white dots, or squiggly lines. Some patients may experience a field cut, meaning a person may not see part of their vision on one side. All patients in Miller Fisher’s study underwent cerebral angiography (a special type of imaging study to evaluate the blood vessels in the brain), and the results were either normal or revealed subtle changes which did not sufficiently explain the cause of the symptoms. Dr. Miller Fisher concluded that the patients’ presentations might be consistent with migraine, despite the fact that only 50% of patients in the series suffered from headaches at the time of the TIA episode. In 1986, Dr. Miller Fisher reported his second case series of 85 patients with transient late-life migraine accompaniments (TMA). The patients in the study were 60% men and 40% women, with 40% of patients aged 50 to 59 years, 20% age 60 to 69, and 16% were over the age of 70. The study classified the migraine accompaniments into various categories as follows: visual (19) visual and paresthesias (6) visual and speech disturbance (2) visual, paresthesias, and speech disturbance (3) visual, paresthesias, speech disturbance, and paresis (20) visual and brain stem symptoms (3) no visual accompaniments but only paresthesias, speech disturbance, and paresis (32) www.headaches.org | National Headache Foundation 23