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Occasionally patients in the stroke age-bracket over 40 years have unexplained transient cerebral ischemic attacks in association with normal cerebral angiograms. From this group, 120 have been collected in whom the transient episodes resembled the neurological accompaniments of migraine. According to symptoms, the patients were categorized as follows: visual accompaniments (patients with only ordinary scintillating scotoma were excluded), 25; visual and paresthesias, 18; visual and speech disturbance, 7; visual, and brain stem symptoms, 14; visual, paresthesias, and speech disturbance, 7; visual, paresthesias, speech disturbance, and paresis, 25; recurrence of old stroke deficit, 9; miscellaneous, 8. In establishing the diagnosis, angiography is advisable in all but classical cases. Typical of migrainous accompaniments are the build-up and migration of visual scintillations, the march of paresthesia, and progression from one accompaniment to another, characteristics that do not occur in thrombosis and embolism. Diagnosis facilitated when 2 or more similar episodes have occurred or migraine-like scintillations are present. Headache occurred in 50% of cases. Other cerebrovascular processes, coagulation disorders, and cerebral seizures must be ruled out.
Dr. Young is an Associate Professor in the Department of Neurology and Jefferson Headache Center, Thomas Jefferson University, Philadelphia, Pennsylvania.
For the field of headache medicine, C. Miller Fisher's 1980 article, Late-Life Migraine Accompaniments as a Cause of Unexplained Transient Ischemic Attacks, is a veritable Mount Everest of clinical description.1 Dr. Fisher's contributions to neurology generally are monumental. He coined the terms transient ischemic attack, the “one-and-a-half” syndrome, string sign, ocular bobbing, and wrong-way eyes. He provided the seminal descriptions of many disorders, including the clinical manifestations of carotid artery disease, most of the lacunar syndromes, thalamic and cerebellar hemorrhage, motor impersistence from right hemisphere disorders and, of course, the Miller Fisher syndrome.2 Even so, in my opinion, it was his description of migraine accompaniments that stands out . . . if only because so little had been written or discussed concerning this topic before his article appeared, and so little could be added after, his description being so complete.
Before 1980, scintillating scotoma typical of migrainous aura but occurring relatively late in life was recognized, but there were no clinical descriptions of other aura-like syndromes occurring in the elderly. Dr. Fisher described 120 patients who experienced one or more attacks of aura that had not occurred before age 40 years and were not confined to isolated scintillations only. His “migraine equivalents” included: scintillating scotomata, paresthesias, aphasia, dysarthria, hemiplegia, blindness, hemianopia, ophthalmoplegia, oculosympathetic palsy, mydriasis, confusion or stupor, cyclical vomiting, seizures, diplopia, deafness, recurrence of old stroke deficit, and chorea. An observation I would add is that some of these accompaniments we assume are caused by cortical spreading depression (eg, paresthesias), but others (eg, mydriasis) may stem from other mechanisms.
Dr. Fisher used the features of typical migraine (duration, march, sequential symptoms) as a guidepost, accepting only subjects with normal examinations and normal cerebral angiograms (the magnetic resonance imagings of the day). He found 78 patients had visual symptomotology with or without other types of symptoms, 25 had nonvisual accompaniments only, and 9 had recurrence of old stroke deficit. He then set forth the “rules” that continue to be the uncontested basis for diagnosis: (1) visual aura is most common, with paresthesias next and followed by aphasia, dysarthria, and paralysis; (2) build-up; (3) march; (4) progression from one accompaniment to another; (5) 2 or more similar spells; (6) duration 15-25 minutes; (7) temporally associated headache; (8) mid-life “flurry” of accompaniments; (9) benign course; (10) normal imaging; and (11) exclusion of other conditions. Unlike current classification systems, Dr. Fisher does not tell us how many of these are required for a diagnosis. Use your clinical judgment!
Once you learn of this symptom complex, you see it over and over again. It is easy to diagnose . . . even obvious. But just to make sure, Dr. Fisher published another 85 cases.3 No one since has changed his clinical characterization, much less improved upon it. The International Headache Society reacts by tactfully ignoring it.
His writing is strange by today's standards, with his introduction, results section, and conclusion all mixed together, and much of the article is composed of illustrative cases. But once you slog through, you really will have the flavor of the condition, and when you are confronted with it, you are reassured, you reassure your patient, and common sense rules your management.