This post briefly summarizes and highlights key portions of SSR 19-4p, the Social Security Ruling about headache disorders, that should help you in preparing for or briefing a headache claim. It also describes how ClaimData can help you develop evidence to better support a headache claim.
Introduction
The Ruling begins by distinguishing primary and secondary headaches and then describing detailed diagnostic criteria for the various primary headache disorders: migraine with and without aura, tension type headaches, and cluster headaches.
Establishing an MDI
Next comes the critical standard for establishing an MDI of primary headache disorder:
Diagnosis by exclusion
“The evidence must document that the AMS [acceptable medical source] who made the diagnosis reviewed the person’s medical history, conducted a physical examination, and made the diagnosis of primary headache disorder only after excluding alternative medical and psychiatric causes of the person’s symptoms. In addition, the treatment notes must be consistent with the diagnosis of a primary headache disorder.”
Observation of a headache
“An observation of a typical headache event, and a detailed description of the event including all associated phenomena, by an AMS … In the absence of direct observation of a typical headache event by an AMS, we may consider a third party observation of a typical headache event, and any co-occurring observable signs, when the third party’s description of the event is documented by an AMS and consistent with the evidence in the case file.”
Remarkable or unremarkable findings on laboratory tests.
“While imaging may be useful in ruling out other possible causes of headache symptoms, it is not required for a primary headache disorder diagnosis.”
Response to treatment
“We will consider whether the person’s headache symptoms have improved, worsened, or remained stable despite treatment and consider medical opinions related to the person’s physical strength and functional abilities. When evidence in the file from an AMS documents ongoing headaches that persist despite treatment, such findings may constitute medical signs that help to establish the presence of an MDI.”
Primary Headache Disorders at Step 3
Next the Ruling describes how primary headache disorders are evaluated under the Listings. There’s no headache Listing so primary headache disorders are evaluated under paragraphs B and D of 11.02 (Epilepsy).
Primary Headache Disorders and RFC
The Ruling concludes with a brief discussion about determining a claimant’s RFC due to a primary headache disorder:
“Consistency and supportability between reported symptoms and objective medical evidence is key in assessing the RFC.”
By helping clients track their symptoms every day, ClaimData necessarily leads to greater consistency in their reports to providers. And the summary reports the platform generates provide an ideal way for medical providers to understand the client’s functioning so they can then formulate a correct and credible RFC opinion.
In fact, SSR 19-4p expressly affirms the usefulness of a platform like ClaimData:
“It is helpful to a physician when a person keeps a ‘headache journal’ to document when the headaches occur, how long they last, what symptoms are associated with the headaches, and other co-occurring environmental factors.”
ClaimData is an especially useful ‘headache journal’ because it documents and summarizes the specific information Social Security uses to evaluate the severity of a person’s condition as described in the Ruling:
“…the frequency of headache events; adherence to prescribed treatment; side effects of treatment … Limitations in functioning that may be associated with the primary headache disorder or effects of it treatment, such as interference with activity during the day…”
ClaimData provides an easy way for you to obtain important supplemental evidence to document your clients limitations: whether due to headaches or most other health conditions.
I couldn’t find an app or software that met my specific needs so I created ClaimData to help attorneys like myself and the clients we have the privilege to represent. If you can think of any way that ClaimData can better help you do this important work, please get in touch. Thank you for representing the sick and injured.