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Migraine with aura (MA) usually presents before the age of 40. De novo diagnosis above this age may require investigation to exclude other causes (transient ischaemic attacks [TIAs], neoplasm, temporal arteritis, epilepsy, pituitary macroadenoma [1]) and comorbid pathologies, especially stroke [2]. Cases of de novo postmenopausal migraine are reported, sometimes with familial basis [3], but these episodes are usually without aura. How late in life first presentation of MA may occur is not clear. A case with onset in the eighth decade is described. A 72-year-old lady presented with a 2-month history of intermittent, stereotyped attacks, occurring 2–3 times per week, commencing with flashing lights before the eyes which developed over 20–30 min into a visual field defect to one side, followed by frontal throbbing headache. There was no associated nausea or vomiting but she preferred to lie down in a quiet room with the curtains drawn. Headache gradually settled with simple analgesia (paracetamol). The patient could recall no previous history of similar headaches. Her son developed MA as a teenager. Neurological examination and structural brain imaging (CT) were normal. The history was consistent with a diagnosis of MA [4]. First onset of MA in the elderly has rarely been described [1], although age at onset does not feature in ICHD2 diagnostic criteria [4]. It might be argued that this patient in fact had earlier onset of MA, which then remained dormant for many decades, and had simply forgotten previous attacks. However, the distinctiveness and severity of MA is such that prior attacks are unlikely to escape the memory. Nothing in the history suggested TIAs [1] or other comorbid pathologies [2]. Spontaneous, atraumatic, dissection of the carotid [5] or vertebral [6] artery has been reported to mimic migraine but symptoms are usually transient rather than persistent as in this case. Thus, despite appropriate differential diagnostic caveats, MA may present de novo in the elderly. Received: 13 July 2007 Accepted in revised form: 26 July 2007 Published online: 24 September 2007

Late onset migraine with aura: how old is too old?