Systematic review of late-onset aura related to migraine: an overlooked phenomenon

The age of onset of migraine with aura (MwA), is frequently observed between the second and third decades. However, patients presenting with late-onset MwA (LOA) are not rare in clinical practice. This systematic review aimed to investigate the literature on the LOA after the age of 50 to shed light on this underexplored topic. A systematic literature search from PubMed and Cochrane databases was performed by using the search terms: “migraine with aura and late onset or over 50 or after 50 or onset in elderly or delayed onset” and “late-life migraine accompaniments” for articles published between July 1987 to October 2023. Out of the 660 papers that were scanned blindly, 8 eligible studies were finally evaluated in detail. A total of 394 patients with LOA were evaluated. Female/male ratio was 3/1. The mean age of onset was 56.25 ± 1.65 years. The most prominent type of aura was visual (93.6%) akin to the early age of onset (EAO) patients but the duration of auras was shorter (frequently ≤ 20 min). A substantial number of auras emerge solely (31.2%) and when aura was followed by a headache, non-migrainous headache features (50%) were more pronounced. The family history of headache (47.7%) was similar to the EOA. Secondary LOA-mimics were also reported but the neuroimaging data were very limited. In conclusion, the absence of an accompanying headache or the presence of non-migrainous headache characteristics are important in differential diagnosis of LOA. Future research is warranted to elucidate the underlying mechanisms.