A 42-year-old White woman presents with chronic migraine headache. She began experiencing two to four headaches per month 3 years ago and was able to successfully manage them in a primary care setting with a caffeinated analgesic combination.

A year and a half ago, her headaches increased in number, severity, and duration to eight migraines per month on average, with aura in the form of visual disturbances (floaters) and photophobia, each lasting from 24 to up to 72 hours at a time. She experienced nausea and often vomited during these episodes and reported being exhausted when the headache resolved. She was referred to a neurologist and was prescribed lasmiditan to use for severe headaches only, in place of the caffeinated analgesic combination. Her physician did not offer preventive treatment at that time. The patient now experiences an average of 20 headache days per month. Her headaches often do not resolve completely. She has abandoned using the caffeinated analgesic combination altogether and takes lasmiditan at the first sign of headache, multiple times per week.

Physical exam shows normal vital signs. MRI is negative for mass lesion or intracranial pressure. The patient has a history of colon cancer that was successfully treated with surgical resection and chemoradiation 10 years ago. The disease has been in remission ever since. Otherwise, her medical history is unremarkable. She drinks several glasses of wine multiple days per week and consumes a substantial amount of refined sugar in the form of candy and chocolate.