50 year old male with 20 non specific bilateral punctate predominantly frontal white matter lesions. 6 years ago there were 3 now theres 20. should i be worried? my neurologist referred me to a headache specialist but i dont get headaches?

Most likely related to poorly controlled high blood pressure (more that 120 systolic). If it has been normal and only one arm used check the other arm, The left arm has smaller blood vessels coming off aorta and can get blocked resulting in BP differences in blood pressure or up to 50 mm Hg. Does your retinal exam show evidence of high blood pressure?

Some causes of such lesions include aging, high blood pressure, microvascular angiopathy, smoking, prior head injuries, multiple sclerosis, and migraine. If you had a history of migraine, this would NOT necessarily explain your lesions, as migraine T2 lesions are usually posterior, not over frontal areas!