Transient visual and neurological episodes are relatively common and can occur for the first time in middle and old age. In many cases these transient events are migraine auras. An aura is a transient, stereotypical, visual or neurological episode usually lasting 4 to 60 minutes in duration. Migraine is usually, but not always, associated with headache and can be accompanied by systemic and autonomic symptoms. Diagnosis is dependent on International Headache Society criteria. The pathophysiology is believed to involve neurovascular mechanisms. There is a hereditary component to migraine. When migraine auras occur in the absence of headache they are termed acephalgic migraines. Late onset migraine accompaniment is an acephalgic migraine that presents in middle-aged and older adults. It is usually benign. Migraines can be mimicked by other more serious conditions. Most patients with a stable migraine pattern and normal neurological evaluation do not require further testing. Some patients with atypical presentation, older age, or suspected secondary causes need further investigation.