Paroxysmal hemicrania (PH) is characterized by frequent, short-lasting, severe, unilateral headaches that occur in association with cranial autonomic features. The hallmarks of this syndrome are relatively short attacks and a complete therapeutic response to indomethacin. Although PH has been classified as strictly unilateral headache in association with cranial autonomic features, a few cases have been reported that suggest bilateral PH. We report a case of PH with bilateral distribution and bilateral autonomic features. PH may actually represent a clinical spectrum including different phenotypes.