A previously healthy 38-year-old woman developed chronic urticaria. Her initial laboratory evaluation had included normal thyroid function tests and mildly elevated thyroid peroxidase antibodies. Because she responded poorly to standard therapy with antihistamines and corticosteroids, she was referred to endocrinology for assistance with clinical management. A brief therapeutic trial of levothyroxine had no impact upon the frequency or severity of urticaria; the patient then self-discontinued her medication. Two months later, she developed new complaints of heat intolerance, diaphoresis, and diffuse myalgias and arthralgias. Subsequent laboratory studies confirmed new-onset hyperthyroidism, with a thyrotropin level of <0.01 mU/L, elevated thyroxine levels, and high levels of thyroid-stimulating immunoglobulin (352%). Nuclear imaging studies confirmed the clinical diagnosis of Graves disease. Hyperthyroidism responded to medical therapy with propylthiouracil; however, her chronic urticaria lesions increased in both frequency and severity. After conversion to methimazole failed to affect her clinical course, the patient elected a near-total thyroidectomy. Within just 10 days of surgery, her skin lesions improved dramatically; urticarial lesions then resolved completely within several weeks. In this report, we first discuss the well-documented association between chronic urticaria and autoimmune thyroid disease. We then review the existing (and controversial) evidence for treating thyroid autoimmunity in patients with chronic urticaria.