Differential Diagnosis for a 14-year-old with Transient Left-sided Tingling, Slurred Speech, and Headache

• Single most likely diagnosis:
  • Migraine with aura: This condition is characterized by transient neurological symptoms such as tingling, speech disturbances, and is often followed by a headache. The symptoms described, including the resolution of neurological deficits followed by a headache, are classic for a migraine with aura, which can start in adolescence.
• Other Likely diagnoses:
  • Transient ischemic attack (TIA) or minor stroke: Although less common in adolescents, TIAs or minor strokes can present with similar transient neurological deficits. The presence of a headache could be related to the vascular event or a separate condition.
  • Multiple sclerosis (MS): MS can present with a wide range of neurological symptoms, including tingling and speech difficulties, and is known for its relapsing-remitting course. However, the headache in MS is not typically a prominent feature unless associated with an acute relapse or a separate condition.
  • Complex partial seizure: Seizures can manifest with a variety of symptoms, including tingling, speech disturbances, and post-ictal headaches. The transient nature of the symptoms could suggest a seizure, especially if there were other signs such as altered consciousness or automatisms.
• Do Not Miss diagnoses:
  • Arteriovenous malformation (AVM) or other vascular anomalies: These conditions can cause seizures, headaches, and transient neurological deficits due to bleeding or ischemia. Missing such a diagnosis could be catastrophic if it leads to a significant hemorrhage.
  • CNS vasculitis: Inflammation of the blood vessels in the central nervous system can lead to a variety of neurological symptoms, including headaches and transient deficits. This condition requires prompt diagnosis and treatment to prevent further damage.
  • Subarachnoid hemorrhage: Although rare in adolescents, a subarachnoid hemorrhage can present with sudden headache and transient neurological symptoms. It is crucial to consider this diagnosis due to its high morbidity and mortality.
• Rare diagnoses:
  • Mitochondrial disorders: Conditions like MELAS syndrome (mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes) can present with stroke-like episodes, headaches, and a variety of other neurological symptoms. These disorders are rare but should be considered in the appropriate clinical context.
  • Fabry disease: This genetic disorder can cause a variety of systemic and neurological symptoms, including transient ischemic attacks, headaches, and neuropathic pain. It is rare but important to diagnose due to the availability of specific treatments.