J.R. presents to her PCP with a chief complaint of “pounding and throbbing” headache, and this is the fourth time this month she has experienced this type of headache. The patient is a 45-year-old Caucasian female who appears slightly overweight. She describes her headache at the right temple and having a pain score of 9/10. She denies any pain in the orbit or cheek. She denies lacrimation and rhinorrhea. She is sensitive to the lights in the clinic which make her feels nauseous and dizzy but has not vomited. She denies sensitivity to sound. Previous similar headaches have lasted about 6 hours, have not been responsive to any type of OTC medication, and do not appear to be associated with menses. In addition, she feels exhausted when the headaches finally subside and often fall into a long, deep sleep afterward. She has no known allergies, does not use alcohol or tobacco products, and denies the use of illegal drugs. She sleeps only about 5 hours every night and has rather poor eating habits. She eats “more chocolate than she should” and drinks three or four caffeinated soft drinks everyday.

Blood Chemistry Panel

Na+ = 144 meq/L
K+ = 3.7 meq/L
Ca+2 = 8.5 mg/dL
Mg+2 = 0.9 mg/dL
PO4-3 = 2.7 mg/dL
Cl- = 110 meq/L
HCO- = 30meq/L 3

List four potential precipitating factors or contributing factors for migraines in this patient. Explain your answer.
Identify the single abnormal finding in the blood chemistry panel above and explain its possible association with the patient’s migraine headaches.
Identify five features of the patient’s headache that help exclude cluster headache as a potential diagnosis.