The aim of this case report is to describe rare form of migraine in pediatric patient and to point out difficulties of making the right diagnose and classification according to ICHD-III (International Headache Society 2018.)

Case Report A 14-year old girl driven by emergency team to pediatric emergency from school where she had severe unilateral headache with nausea and paresthesia in the right hand and leg about an hour before arrival. At arrival she was confused, unknowing the name of her school and dysphasic. Neurological exam showed dysphasia and right hemiparesis, in the next half an hour she was somnolent, only opening her eyes when shaken and started vomiting.

After two hours (three from the first simptoms) all clinical signs vanished, she was in her full consciousness, ambulatory with no neurological deficits!

-Brain CT, EEG and MRI/MRA were normal, so did D-dimers and coagulogram, we transported her to tertiary level center

Differential Diagnoses 1. cerebrovascular disease- ischemic or hemorrhagic stoke; transient ischemic attack 2. CNS infections/encephalophaty/brain tumor 3. syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) 4. migraine

Diagnosis and Classification -Diagnosis is clinical, TIME has major role -It is the diagnosis of exclusion- when we exclude diagnosis from above and time shows that the attack was episodic and reversible, we can than afford ourselves to think about migraine -which type of migraine? According to ICHD -III it does not fulfill criteria for hemiplegic migraine since it takes at least two attacks with motor deficit, so we can only classify this case as 1.5.2: probable migraine with aura.

Conclusion Diagnosis of a first episode of sporadic hemiplegic migraine (severe attack) in a pediatric patient is very challenging for a clinician, especially in a first few hours What makes already dramatic clinical picture even harder to diagnose:

-children and adolescents find it hard to describe their aura symptoms- motor aura is necessary feature for the diagnosis, clinician must establish as clearly as possible whether the patient actually experienced motor weakness as an aura symptom -lack of literature about this cases; no guidelines for the management of acute attacks -signs and symptoms described in all of the other aura types- heterogeneous symptoms Regardless of the new technologies in diagnostic, accessible medical data bases and several headache classifications, some conditions will always remain challenging