This is a followup to the 14yo I mentioned last week with hemiplegia, aphasia and apraxia. FH included maternal hx of 3 episodes of hemiplegic migraines in the last 25yrs with onset at about 16yo and simimlar presentation. Initial CBC was unremarkable. She was admitted for observation overnight(she presentted at 4:30pm). EEG the next morning showed diffuse slowing of the entire left hemisphere. MRI was attempted at that time as well but the patient would not cooperate and none of us felt comfortable with sedating this child until we had a better idea of what was wrong because monitoring and assessing her was so problematic (MMSE score basically <5, difficulty following usual neuro checks due to inconsistent responses or excellent scores but otherwise abnormal sensorium so not helpful). CT was obtained (normal) prior to LP which was unremarkable. With neuro consultant, we decided to start acyclovir on the off chance that this might be herpes meningitis/encephalitis. By that evening, approx 24h following presentation, she was able to state her name, location and age. She was using a hair brush appropriately and asking for food and water appropriately. She still could not name her mother or me. She continued to improve overnight and was discharged at about 36-48h after presentation in normal mental status with resolving hemiplegia. The MRI was never completed and the acyclovir was stopped since she began to improve almost simultaneously with receivng the first dose. Final diagnosis: acute hemiplegic migraine. I have to say this was one of the most frightening children I ever cared for because, as with many neurologic illnesses, her presentation was not consistent with most of the more common things we handle in primary peds practice (and somewhat 'illogical'). Also because her neuro exam was not consistent with any of the other differential diagnoses, although we also felt compelled to r/o other more serious possibilities such as stroke or infection, since intervention would be required for most if not all of them. Time, as it frequently does, gave us the answer. Thanks for your discussion and comments. Dr. Carol Carol F. Teplis, MD Associates in Pediatrics Elgin and Streamwood, Illinois