On August 26, 2019, SSA issued Social Security Ruling 19-4p, “Titles II and XVI: Evaluating Cases Involving Primary Headache Disorders” to provide guidance on how headache disorders are evaluated and the kind of evidence SSA will consider sufficient to establish an impairment.
The SSR relies on the third edition of the International Classification of Headache Disorders (ICHD-3) to define primary headache disorders as “complex neurological disorders involving recurring pain in the head, scalp, or neck….typically severe enough to require prescribed medication and sometimes warrant emergency department visits.” Primary headache disorders –for example, migraines, tension-type headaches, and trigeminal autonomic cephalalgias – are distinguished from secondary disorders as occurring independently and not caused by another medical condition. A secondary headache disorder cannot be established as a medically determinable impairment.
A primary headache disorder is a diagnosis of exclusion, and made after other potential causes are ruled out. To establish a primary headache disorder as a medically determinable impairment, SSA will look for a combination of findings by an acceptable medical source. Findings include: a diagnosis; observation and detailed description of a typical headache event and any co-occurring observable signs; laboratory testing; and responses to treatment. In lieu of direct observation by the acceptable medical source, SSA may consider a third party observation and description of a typical headache when it is documented by an acceptable medical source.
SSR 19-4p notes that objective evidence such as imaging scans may be helpful to exclude other diagnoses, but they are not necessary. Notably, the SSR discusses the usefulness of “headache journals” kept by a patient to document the frequency and characteristics of a headache. It advises that a journal can be helpful both as a diagnostic tool for the physician and also to an adjudicator as a source of evidence that SSA will consider “when it is part of the record, either as part of the treatment notes or as separate evidence, along with all evidence in the record.”
The SSR acknowledges that headache disorders are not included among SSA’s listed impairments. The SSR provides guidance, however, on how a primary headache disorder may equal a listing, looking specifically to Listing 11.02B and 11.02D for epilepsy as the most closely analogous impairment. While stating it is uncommon, SSA notes that detailed information from an acceptable medical source describing a claimant’s typical headache event can be relied upon to find duration and severity equal to the criteria in Listing 11.02B for dyscognitive seizures. The SSR offers some examples of the kind of descriptions that would be useful. Additionally, evidence of those same factors from 11.02B combined with evidence of a marked functional limitation can potentially be shown to equal paragraph D of 11.02.
The ruling goes on to offer an example of the kinds of limiting effects that can result from headache disorder, citing the symptom of photophobia as potentially diminishing a person’s ability to sustain attention and concentration. The SSR reminds everyone that “[c]onsistency and supportability between reported symptoms and objective medical evidence is key in assessing the RFC.”