Brief Question:
We are often asked whether a claimant can receive disability benefits for migraine headaches. Social Security has actually addressed this question in SSA Q&A 09-036, which posed the following “Brief Question”: “Please provide guidance regarding the evaluation of migraine headaches.” A PDF of the Q&A can be downloaded here: SSA-QA_09-036
Detailed Question:
Social Security’s regulations state that it cannot establish a disabling condition based on symptoms alone. According to the medical literature, there are no laboratory findings or clinical signs to substantiate the presence of migraine headaches in most cases. The diagnosis of migraine headache is usually established through patients’ reported symptoms (pain, photophobia, nausea). Previous guidance from the Office of Disability from the early 1990’s stated that, although migraine headaches that are disabling for 12 continuous months in spite of treatment are extremely rare, there are some cases that do not respond to treatment. The guidance said to consider whether the impairment medically equals listing 11.03 based on “altered awareness.”
The more detailed questions posed in the Question and Answer are as follows:
What criteria should Social Security use to determine that migraine headaches are a medically determinable impairment (MDI)? Is a diagnosis from an acceptable medical source sufficient, even if it is based only on a claimant’s reported symptoms? If not, what evidence establishes the MDI?
If Social Security uses listing 11.03 to evaluate migraine headaches, should Social Security use POMS DI 24580.001/Social Security Ruling (SSR) 87-06 to evaluate migraine headaches? If so, what constitutes appropriate treatment and an ongoing treatment relationship?
The POMS/SSR also say that Social Security needs a description of a seizure from professional observation or a third party. Does this guidance apply to migraine headaches?
The POMS/SSR also say that Social Security needs a record of anticonvulsant blood levels in every case before it can allow a claim unless there is convincing evidence that subtherapeutic drug levels are due to abnormal absorption or metabolism and the prescribed drug dosage is adequate. Is there an analogous medically acceptable way to determine if an individual is taking headache medications appropriately? If not, how should SSA assess compliance with treatment?
What is “altered awareness” and how is it measured?
Answer:
Because of significant changes in the diagnosis and treatment of migraine headaches since Social Security provided guidance in memorandums from the early 1990’s, Social Security is rescinding that guidance and temporarily replacing it with the guidance in this Q & A while Social Security prepares proposed updates to the neurological listings. However, as explained below, there is little change in the guidance Social Security originally provided.
Under Social Security’s general policy, you cannot establish the existence of any MDI based solely on a diagnosis in the evidence or on a claimant’s reported symptoms. There must be clinical signs or laboratory findings to support the finding. A diagnosis of migraine headaches requires a detailed description from a physician of a typical headache event (intense headache with more than moderate pain and with associated migraine characteristics and phenomena) that includes a description of all associated phenomena; for example, premonitory symptoms, aura, duration, intensity, accompanying symptoms, and effects of treatment. The diagnosis should be made only after the claimant’s history and neurological and any other appropriate examinations rule out other possible disorders that could be causing the symptoms. There are other clinically accepted indicators of the diagnosis, including:
- Headache event that lasts from 4 to 72 hours if untreated or unsuccessfully treated.
- Two of the following: Unilateral, pulsating (throbbing) quality; moderate (inhibits but does not wholly prevent usual activity) or severe (prevents all activity) pain intensity, worsened by routine physical activity (or causing avoidance of activity).
- At least one of the following during the headache: Nausea, vomiting, photophobia, or phonophobia.
Once other possible causes have been ruled out and a pattern has been established, Social Security considers the foregoing findings reported by a physician to be “signs” that establish the existence of migraine headaches as an MDI. This is consistent with the way the SSA establishes the existence of some mental disorders and other physical disorders that are characterized by complaints reported by acceptable medical sources based on their examinations.
As in Social Security’s earlier guidance regarding migraine headaches, Social Securitiy continues to recognize that migraine headaches will rarely prevent a person from working for a continuous 12 months but that there are exceptions. Likewise, listing 11.03 (Epilepsy – nonconvulsive epilepsy) is still the most analogous listing for considering medical equivalence. However, the guidance in POMS DI 24580.001 / SSR 87-06 is specific to epilepsy and not applicable to the evaluation of migraine headaches. Social Security does not consider treatment non-compliance or therapeutic levels of medication in the blood because, unlike treatment for epilepsy, which seeks to maintain a steady level of medication in the blood, there is no such standard of care in the treatment of migraine headaches. Also, therapeutic blood levels for migraine medication have not been established. Nor does Social Security require a professional observation or third-party description of a migraine headache event, although such observations are helpful. Social Security requires a professional observation or third-party description of a seizure partly because the person having the seizure is unaware of it and cannot describe how s/he looks during a seizure. This is not the case for migraine headaches.
It may be helpful to review the essential components of listing 11.03 as they may be related to migraine headaches:
- “Documented by detailed description of a typical” headache event pattern “Including all associated phenomena”; for example, premonitory symptoms, aura, duration, intensity, accompanying symptoms, treatment.
- “Occurring more frequently than once weekly.” Count characteristic headache events.
- “In spite of at least 3 months of prescribed treatment.” Inapplicable, as explained above.
- “With alteration of awareness.” This means a condition of being inattentive, or not cognizant of one’s surroundings and external phenomena as well as one’s personal state. Many psychotropic and neuroleptic medications used for treating migraines can produce sedation, confusion, or inattention. However, it is not necessary for a person with migraine headaches to have alteration of awareness as long as s/he has an effect (e.g., one or more of the problems described in the next bullet) that significantly interferes with activity during the day.
- “Significant interference with activity during the day.” Same meaning as in listing 11.03. May be the result, e.g., of a need for a darkened, quiet room, lying down without moving, or a sleep disturbance that impacts on daytime activities.