“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.
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