Late-life Migraine Accompaniments in Middle Age and the Elderly
R. Allan Purdy MD, FRCPC, Professor of Medicine (Neurology), Dalhousie University, Halifax, NS.
Of all the neurological disorders, migraine is one of the most common and fascinating. In importance, the modern neurobiology of migraine places it among other major neurological conditions of a paroxysmal nature. Migraine occurs at all ages and is not uncommon in middle- and late-life. It can present with aura and no or little headache, and with or without a prior history of migraine in earlier life. Physicians seeing older patients with transient neurological symptoms and headache need to understand the role of migraine in the diagnosis and ensure no other sinister etiology exists or coexists.
Key words: migraine, aura, migraine accompaniment, acephalgic migraine, headache.
Introduction
Clinicians frequently see patients with aura symptoms of migraine who have had no headache or very little headache following the aura. These symptoms are recognised as acephalgic migraine or, literally, migraine without headache. This disorder is classified as "migraine aura without headache" by the International Headache Society,1 and is a migraine variant or equivalent. In the middle-aged and elderly patient, this disorder is what Fisher2 called late-life migraine accompaniments.
Historical Papers
In 1980, Fisher reported a series of 120 patients with neurological accompaniments of migraine, classified according to symptoms, as follows: visual symptoms only (25); visual symptoms and paresthesias (18); visual symptoms and speech disturbances (7); visual and brainstem symptoms (14); visual symptoms, paresthesias and speech disturbances (7); visual symptoms, paresthesias, speech disturbances and paresis (25); recurrence of old stroke deficit (9) and; miscellaneous symptoms (8).2 Headache occurred in 50% of cases reported.
In 1986, Fisher subsequently reported a study of 85 cases that were similarly categorised: visual symptoms (21); visual symptoms and paresthesias (6); visual symptoms and speech disturbances (2); visual symptoms, paresthesias and speech disturbances (3); visual symptoms, paresthesias, speech disturbances and weakness (20); visual and brainstem symptoms (3) and; no visual symptoms (32).3 These cases ranged in age from 40-73 years and 40% had some headache associated with the neurological symptoms, with 65% having a history of recurrent headache. He was particularly interested in patients who had normal cerebral angiograms.
In both of Fisher's papers, a significant number of patients had headache; thus, not all were totally acephalgic or with only aura. The essence of his original communication was to explain why patients in the stroke age-bracket (older than 40 years) occasionally have unexplained transient cerebral ischemic attacks in association with normal cerebral angiograms. He emphasized that these occasional patients probably had migraine aura mainly, although those with headache were more clearly suffering migraine.
Fisher was not the only one to note the phenomena of significant aura symptoms without headache. In 1967, Whitty indicated that migraine auras in middle-age could occur without a headache following the aura, and that this was more common in people who had prior migraine in the past.4
Transient Migraine Accompaniments (TMAs)
Today, these late-life migraine accompaniments are considered to be transient migraine accompaniments, or TMAs, and are recognised to be generally benign in nature but are of important diagnostic interest. Migraine with aura (formerly called "classic migraine") is distinguished from migraine without aura (formerly "common migraine") by the neurological symptoms of aura rather than the headache symptoms.1 Furthermore, headache can occur in patients with transient ischemic attack (TIA) or stroke,1,5 although this is not always recognised or appreciated.
Case Presentation
For five years, a man aged 58 had one or two spells each year of combined visual and speech disturbance. For six months, spells occurred two or three times a week. In a spell, the ability to focus was lost