LATE-ONSET migraine with aura in patients over 50 is gaining attention as a clinically distinct and underrecognized presentation, according to a new systematic review. While migraine with aura typically begins in early adulthood, clinicians are increasingly encountering cases where onset occurs much later in life—prompting questions about diagnosis, differential symptoms, and potential mimics.
The review, which evaluated 8 eligible studies from 660 scanned publications, focused on cases of migraine with aura beginning after age 50. The findings encompassed 394 patients, with a notable predominance of women (female-to-male ratio of 3:1) and an average age of onset at 56.25 years.
In late-onset aura (LOA), visual symptoms were by far the most frequent presentation, reported in 93.6% of patients. However, the aura duration was shorter than in early-onset cases, often lasting 20 minutes or less. Unlike classical migraine presentations, nearly one-third (31.2%) of auras occurred without a subsequent headache, and when headaches did follow, 50% lacked migrainous characteristics.
Family history of headaches was similar to early-onset cases, present in 47.7% of individuals. While the review aimed to distinguish true LOA from secondary mimics, such as stroke or other neurologic disorders, the authors noted a lack of comprehensive neuroimaging data in the studies analyzed—limiting conclusions about pathophysiological mechanisms.
The authors emphasize that recognizing LOA as a unique clinical entity is critical. The frequent absence of migraine-like headaches or the presence of atypical headache features challenges standard diagnostic criteria and calls for greater awareness among clinicians, particularly when evaluating older adults with transient visual or sensory disturbances.
Further studies are recommended to better understand the biological basis and optimal management strategies for LOA. Clinicians should maintain a high index of suspicion and consider neuroimaging to exclude secondary causes when diagnosing migraine with aura in patients over 50.
Reference:
Atalar AÇ et al. Systematic review of late-onset aura related to migraine: an overlooked phenomenon. Acta Neurol Belg. 2025. doi: 10.1007/s13760-025-02799-8.
