HeadWise HeadWise: Volume 6, Issue 2 - Page 25

“Migraine attacks occurring late in life may also be accompanied by transient neurologic symptoms like visual changes, speech disturbances, paresthesias, and weakness.” As mentioned previously, auras gradually progress over time, and then the paresthesias may begin to resolve, with the first area involved clearing while the next region becomes involved. TIAs often cause complete loss of sensation on one side of the body (numbness). These symptoms will occur throughout the entire side or limb simultaneously, so the face and arm may be completely numb at the same moment. Then as quickly as the sensation occurred, it resolves abruptly. Sensory changes in the mouth or tongue are rarely due to TIAs. Migraine auras must also be differentiated from seizures, and the visual symptoms for each are sometimes more difficult to distinguish, especially if the headache is mild or completely absent at the time of presentation. Seizures which originate from the occipital lobe, where vision is processed by the brain, can cause transient visual changes. These visual changes are frequently characterized as colorful circles or balls that are bright and multiple within the field of vision. The circles may change colors, and often begin on the outer side of one's vision, and then move towards the middle or to the opposite side. The circles may increase in number and size, and often the seizure lasts for seconds to at most a few minutes. The visual auras of migraine, while they do change and progress over time, are commonly black and white and either linear or zigzags, although some patients report they experience multiple colors where the zigzag lines are seen. “Late-life migraine accompaniments” are often recurrent. It is important to consider underlying medical issues before initiating any medications or other treatments. There have been no randomized controlled trials researching specific treatments for late-life migraine accompaniments. However, most physicians treat these episodes similarly to classic migraine with aura. Some classes of medications that may act as preventives include beta-blockers (propranolol, metoprolol), antiepileptics (valproic acid, topiramate, gabapentin, lamotrigine), and antidepressants (amitriptyline, nortriptyline, venlafaxine), among others. Commonly used anti-inflammatory medications (acetaminophen, ibuprofen, naproxen) often have no effect on aura symptoms. Triptans, while often very effective for the treatment of migraine headaches, do not alter the aura or its progression. Triptans are avoided in elderly patients with risk factors for heart disease and stroke. Conclusion It is not rare for patients to experience their first migraine late in life. Migraine attacks occurring late in life may also be accompanied by transient neurologic symptoms like visual changes, speech disturbances, paresthesias, and weakness. Visual symptoms and paresthesias are the most common “late-life migraine accompaniments.” These symptoms are often recurrent and stereotyped, and they evolve over the course of the episode, sometimes progressing from one symptom modality to another within the same episode. While “late-life migraine accompaniments” are benign, it is important to exclude other causes of these symptoms, such as transient ischemic attacks, seizures, or brain hemorrhages. Further research is needed regarding specific treatments for “late-life migraine accompaniments,” especially for the acute management of the aura-like symptoms in the elderly population. HW 1. Fisher CM. Late-life migraine accompaniments as a cause of unexp lained transient ischemic at- tacks. Canadian Journal of Neurological Sciences 1980;7:9-17. 2. Fisher CM. Late-life migraine accompaniments: Further experience. Stroke 1986;17:1033-1042. 3. Vongvaivanich K, Lertakyamanee P, Silberstein SD, Dodick DW. Late-life migraine accompa- niments: A narrative review. Cephalalgia 2015; 35:894-911. www.headaches.org | National Headache Foundation 25