Late-life migrainous accompaniments

R Allan Purdy MD (Dr. Purdy of Dalhousie University and Queen Elizabeth II Health Sciences Center in Nova Scotia, Canada received honorariums from Gamma Core, Merck Canada, and Tribute Pharmaceuticals for service on medical advisory boards and presenting educational symposia.)
Stephen D Silberstein MD, editor. (

Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura,  INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals,  Thernica and Trigemina for consulting. He is also the  principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.

Originally released November 4, 1993; last updated September 5, 2018; expires September 5, 2021

This article includes discussion of late-life migrainous accompaniments, late-life acephalgic migraine, late-life migrainous equivalents, transient migraine accompaniments, and transient migraine equivalents. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Historical note and terminology

Late-life migrainous accompaniments, a topic of historical interest, is a clinical concept that is still important to modern-day neurologic diagnosticians and students of migraine. Miller Fisher published his 2 seminal articles on late-life migrainous accompaniments in 1980 and 1986. In his combined case series of 205 patients, Fisher was attempting to differentiate late-life migrainous accompaniments from the symptoms and signs of transient ischemic attacks (Fisher 1980; Fisher 1986).

In his first series, Fisher reported 120 patients with neurologic accompaniments of migraine classified according to the following symptoms: visual accompaniments (excluding patients who had only ordinary scintillating scotoma) (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). Diagnosis was facilitated when 2 or more similar episodes occurred or migraine-like scintillations were present (Fisher 1980). Headache occurred in 50% of the patients.

In the second series, Fisher reported 85 cases that were similarly categorized: 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) (Fisher 1986). These patients ranged in age from 40 to 73 years. Forty percent had some headache associated with the neurologic symptoms, with 65% having a history of recurrent headache. Fisher was particularly interested in patients who had migrainous accompaniments and normal cerebral angiograms. Headache was present in 40% of cases in this series.

In both of Fisher's studies, many patients had headache; thus, all were not totally acephalgic (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 ischemic attacks in association with normal cerebral angiograms. He believed that these patients probably had migraine aura; those with headache were more typical migraine. Fisher was not the only one to note the phenomenon of aura symptoms without headache. Whitty reported that in middle-age, migraine auras could occur alone, without a headache; this was more common in people who had had typical migraine in the past (Whitty 1967).

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