Ocular migraine comes without headache

DEAR DR. ROACH: In a recent column, you wrote that migraine of any kind starting in a person’s 60s is uncommon.

I am a 66-year-old male in relatively decent health. I have controlled blood pressure and cholesterol. In the past six months I have started following a “plant-centric” diet and my blood pressure and cholesterol are well within guidelines. My heart rate is in the 43-47 beats per minute range and I have lost over 29 pounds since October 2019. I weigh 217 pounds and six feet, three inches tall.

I recently went for my annual vision check at my eye doctor and told him about seeing a shimmery, jagged, half-moon blur in my vision, mostly on in my left eye, but present in both eyes occasionally.

He did a thorough retina exam and found no abnormality. He speculated that I was experiencing a migraine. I asked why there was no headache associated with the migraine. He said that since I am older and my blood vessels are not as flexible, there is no pain associated with the condition. We chuckled and moved on. The issue is not chronic and I have not had symptoms in over three weeks. Is this something to be concerned about?

ANSWER: Your eye doctor may be right. There is a condition called ocular migraine, also called acephalgic migraine, where people have the aura of a migraine headache but do not develop headache. Most people will get headache sometimes, but a minority of people have never had a headache, only the aura.

However, what I said is also valid. Migraines starting in your 60s are less common, and though this may be the diagnosis, I would be concerned about a transient ischemic attack, which is caused by a loss of blood flow to the brain.

Your eye doctor may not have been able to see anything abnormal in the retina, but I would be concerned enough to consider a look at the blood vessels of the neck and even the brain, an evaluation of your heart rhythm for atrial fibrillation, and some blood testing, to be sure.

TIAs happen mostly in people with risk factors, and although it sounds like you are doing very well now, you may have been at risk in the past. Even people with no risk can get a TIA or stroke.

A neurologist will have expertise in the evaluation of possible TIA, but you can start with your family physician or internist.