Introduction: Hemiplegic migraine is a rare presentation in children and adolescence, and can present with a range of symptoms that can mislead clinicians. Diagnosis can be challenging where neurological symptoms are prominent. Case presentation: A 13 year old girl presented with sudden onset severe unilateral occipital headache, associated with contralateral hemiparesis, loss of vision and aphasia lasting for 45 minutes. All neurological symptoms resolved except for the headache which persisted for several hours. Upon questioning, it was revealed that she had a history of on-and-off unilateral headache for two weeks, but was free of red flag signs. The diagnosis was further confounding as she had a third degree relative who had a young death due to cerebral aneurysm rupture. There were no neurological deficits on examination. Investigations including FBC, ESR, blood picture, clotting profile, ECG, X-ray chest, renal artery and carotid doppler studies, NCCT, EEG and CT angiogram of head and neck were normal. Echocardiogram detected an atrial septal defect, and device closure was done immediately due to the possibility of thromboembolic event. However, the patient presented with similar episodes of TIA despite cardiac intervention, raising the suspicion of hemiplegic migraine. She was started on migraine prophylaxis, and showed an excellent response with no further episodes of headache or hemiparesis, confirming our clinical diagnosis. Conclusion: This case adds to the rare but documented stroke-like presentation of hemiplegic migraine occurring in teenagers. It highlights the importance of excluding neurological etiologies, while clinically diagnosing migraines.