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Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune demyelinating condition of the central nervous system, primarily characterised by optic neuritis and longitudinally extensive transverse myelitis (LETM). While motor and visual symptoms are well-recognised, sensory prodromes such as pruritus are rarely emphasised in clinical descriptions. We report the case of a middle-aged previously healthy woman who presented with a 5-day history of dermatomal itching involving both upper limbs, followed by mild left upper limb monoparesis. Neurological examination revealed isolated left upper limb weakness, with preserved tone, reflexes and sensation. MRI spine demonstrated a longitudinally extensive T2 hyperintense lesion from the cervicomedullary junction to the T8 vertebral level, consistent with LETM. Serological testing confirmed dual positivity for anti-aquaporin-4 and anti-Ro52 antibodies. This case highlights an atypical presentation of NMOSD, with dermatomal pruritus serving as the initial symptom, preceding motor deficit. The case underscores the value of recognising subtle sensory clues in inflammatory myelopathies.