Background: Migraine is the most common primary headache in the pediatric population. Acute Confusional Migraine (ACM) is a variant of migraine that presents with a sudden confusional state, including agitation, disorientation, altered consciousness, speech disturbances, memory impairment, and executive dysfunction, which typically resolves within 24 hours or after sleep. Visual disturbances and aura may also be present. Most patients develop a headache, usually preceding the confusional state. According to a recent study, the prevalence ranges from 0.45% to 7%, being more common in children and adolescents, especially between ages 5 and 17, and more frequent in males.This highlights the importance of considering ACM in the differential diagnosis of pediatric headaches. ACM is a diagnosis of exclusion, and it is essential to rule out other conditions such as infections, seizures, inflammatory, neoplastic, vascular, and metabolic diseases.Case Presentation Summary: A 14-year-old girl with no significant medical history, including no prior history of migraines or headaches, presented to the emergency department with a sudden onset of frontal headache, paresthesias affecting her right hand, left foot, and upper lip, as well as vomiting, disorientation, and dysarthria. These symptoms persisted for approximately two and a half hours. Importantly, the patient did not exhibit photophobia, gastrointestinal complaints such as abdominal pain or diarrhea, and denied fever, respiratory, or genitourinary symptoms. Furthermore, there was no recent history of illness among close contacts, no trauma, or substance abuse. The family history revealed that the patient's mother had a history of migraines.On admission, the patient was afebrile, hemodynamically stable, and cooperative, although she was disoriented with respect to time and place. Her neurological examination was otherwise unremarkable, with no signs of nuchal rigidity or other abnormalities.Laboratory investigations, including a complete blood count, venous blood gas analysis, serum electrolytes, renal function tests, and C-reactive protein, were all within normal limits. Urinary screening for drugs of abuse was negative. A brain CT scan revealed the presence of megacisterna magna and inflammatory sphenoidal sinusopathy, without any signs of acute pathology.The patient's clinical presentation—particularly the acute onset of headache, focal neurological symptoms, and disorientation—warranted immediate intervention, which included analgesia, ondansetron, and fluid therapy. Within six hours of admission, after the patient had rested for about two hours, her symptoms completely resolved.Learning Points/ Discussion: Acute confusional migraine is a subtype of migraine that is still not well understood and presents clinical manifestations that overlap with other pathologies. This rare condition is not included in the third edition of the International Classification of Headache Disorders (ICHD-3), which contributes to underdiagnosis.This case aims to raise awareness of this entity, as early recognition is crucial to avoid unnecessary and invasive diagnostic procedures.
