United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION AND ORDER
A. Ruiz, United States Magistrate Judge.
Suzanne Martin (hereinafter “Plaintiff”),
challenges the final decision of Defendant Nancy A.
Berryhill, Acting Commissioner of Social Security
(hereinafter “Commissioner”), denying her
application for Supplemental Security Income
(“SSI”) under Title XVI of the Social Security
Act, 42 U.S.C. § 1381 et seq.
(“Act”). This court has jurisdiction pursuant to
42 U.S.C. § 405(g). This case is before the undersigned
United States Magistrate Judge pursuant to consent of the
parties. (R. 11). For the reasons set forth below, the
Commissioner's final decision is AFFIRMED.
January 15, 2015, Plaintiff filed her application for SSI,
alleging a disability onset date of November 1, 2002.
(Transcript (“Tr.”) 216-218). The application was
denied initially and upon reconsideration, and Plaintiff
requested a hearing before an Administrative Law Judge
(“ALJ”). (Tr. 111-176). Plaintiff participated in
the hearing on April 11, 2017, was represented by counsel,
and testified. (Tr. 33-83). A vocational expert
(“VE”) also participated and testified.
Id. On May 11, 2017, the ALJ found Plaintiff not
disabled. (Tr. 25). On March 8, 2018, the Appeals Council
denied Plaintiff's request to review the ALJ's
decision, and the ALJ's decision became the
Commissioner's final decision. (Tr. 1-7). On April 23,
2018, Plaintiff filed a complaint challenging the
Commissioner's final decision. (R. 1). The parties have
completed briefing in this case. (R. 12 & 14).
asserts the following assignments of error: (1) the ALJ erred
in failing to account for the effects of migraine headaches
when determining the RFC, and (2) the ALJ's consideration
of the medical opinions of record failed to comport with
State Agency policy and Sixth Circuit precedent. (R. 12).
Relevant Medical Evidence 
December 14, 2012, Jeffrey C. Lamkin, M.D., saw Plaintiff
following a two-year absence since she did not appear for an
appointment in 2010. (Tr. 588-589). Plaintiff thought her
vision was “terrible” and complained of
debilitating migraines. Id. Her vision with
correction was 20/30. Id. Dr. Lamkin recommended
visual fields testing, given Plaintiff's headaches and
the possibility of pseudotumor cerebri. (Tr. 589).
December 21, 2012, Dr. Lamkin referred Plaintiff for
additional evaluation and indicated her visual fields show
severe constriction. (Tr. 587).
January 9, 2013, Clayton Seiple, D.O., examined Plaintiff.
She was 5'3” tall and weighed 228 pounds with a
Body Mass. Index (“BMI”) of 40.38. (Tr. 699-701).
She appeared to be in moderate pain. (Tr. 700). Dr. Seiple
assessed fibromyalgia, other chronic pain, anxiety
unspecified, headaches, allergic rhinitis, and insomnia.
Id. On February 6, 2013, Dr. Seiple again assessed
fibromyalgia, anxiety, and headaches. (Tr. 697). Plaintiff
reported memory loss, headaches, and blurred vision. (Tr.
March 26, 2013, LeRoy LeFever, D.O., saw Plaintiff and
assessed hyperlipidemia, diabetes mellitus, lower back pain,
and fibromyalgia. (Tr. 694). On examination, Plaintiff was in
no acute distress, had no swelling or deformity, and no loss
of sensation. Id.
April 23, 2013, Plaintiff presented to Dr. LeFever reporting
photophobia, phonophobia and a bilateral frontal pounding
headache. (Tr. 689) On examination, Plaintiff was in no acute
distress, was grossly intact neurologically, had an antalgic
gait and walked with a cane, and had 5/5 motor strength in
her upper and lower extremities. (Tr. 690). Dr. LeFever
assessed migraines, diabetes mellitus uncontrolled,
fibromyalgia, anxiety, hypertension, hypercholesterolemia,
vertigo, and neuropathy. Id. Dr. LeFever
administered a Toradol injection for migraine relief.
15, 2013, Dr. LeFever assessed diabetes mellitus uncontrolled
and migraines. (Tr. 687). He believed Plaintiff's
migraines had been caused by analgesia overuse, but noted
that Plaintiff's neurologist believed the headaches were
the result of diabetes. Id.
October 25, 2013, Dr. LeFever assessed diabetes mellitus
uncontrolled, fibromyalgia, obesity, anxiety, hyperlipidemia,
and lumbago, but omitted migraines, headaches, and vertigo.
November 30, 2013, Plaintiff presented to the Emergency Room
with a two-day headache that she described as 10/10 in pain
level. (Tr. 1107). She was diagnosed with a migraine headache
and discharged after receiving medications. (Tr. 1108). On
December 4, 2013, after a return trip to the ER with similar
complaints, she was instructed to see her neurologist within
a week. (Tr. 1099).
4, 2014, Plaintiff saw Rachel Espiritu, M.D., who assessed
diabetes mellitus uncontrolled, diabetic neuropathy,
hyperlipidemia, hypertension, migraines, fibromyalgia, and
obesity. (Tr. 344). Dr. Espiritu emphasized the importance of
dietary changes. (Tr. 344). On examination, her BMI was
39.92, she was in no acute distress, had decreased motor
strength in the lower left extremity, and used a cane for
ambulation. (Tr. 346).
3, 2014, Dr. Espiritu observed decreased left lower extremity
motor strength on examination. (Tr. 349-350).
15, 2014, Plaintiff went to the ER with a migraine, reporting
a history of chronic migraines, that she was suffering from a
week-long migraine, and that her pain intensity was 10/10.
(Tr. 1018). She endorsed both light and sound sensitivity.
Id. She reported taking Topamax daily, and also
trying Tylenol and Ibuprofen. Id. Plaintiff was
given “a headache cocktail consisting of IV fluids,
Zofran, Benadryl, ” which reduced her pain to 7/10, and
subsequent doses of Dilaudid reduced it to 6/10. (Tr. 1020).
Her pain returned, and Plaintiff was admitted for further
management. Id. The provider's impression was
intractable headache, migraines, fibromyalgia, hypertension,
neuropathy, insulin resistant diabetes mellitus, asthma,
anxiety/depression and hyperlipidemia. (Tr. 1032).
16, 2014, sensory exam showed decreased sensation to pinprick
bilaterally in the legs up to the upper shins and a slight
decrease of pinprick sensation over distal finger tips on the
right. (Tr. 888). Sensation to light touch was intact
bilaterally, musculoskeletal bulk and tone were normal,
strength was 5/5 and symmetric bilaterally in the upper
extremities and 4 in the bilateral hip flexor muscles, 5/5
in knee flexion and extension, 5/5/ dorsiflexion on the right
and 4 on the left, plantar flexion was 5/5 bilaterally,
reflexes were 2, and an antalgic gait with use of a cane.
Id. Plaintiff's symptoms were noted as
consistent with acute exacerbation of migraine, prior history
of migraine headaches, and intermittent exacerbations, which
“may have been precipitated by her running out of her
topiramate medication at home.” Id.
November 14, 2014, Dr. Espiritu noted that Plaintiff had
stopped taking Topamax after she ran out, that Plaintiff
“works somewhat, ” and that Plaintiff could not
say how often she gets headaches. (Tr. 321).
November 18, 2014, Dr. LeFever assessed sinusitis and
fibromyalgia. (Tr. 390). He noted Plaintiff recently saw a
neurologist who increased her Topamax prescription.
March 11, 2015, Plaintiff reported that her headaches were
getting better, and that she still wakes up to them, but that
they only lasted “a little bit and then go away.”
8, 2016, Plaintiff reported taking Topamax for three years
for migraine treatment and experiencing migraines three to
four times per month sometimes lasting several days in
duration. (Tr. 879). She was diagnosed with chronic migraines
and continued on Topamax 150 mg as needed and over the
counter medications as necessary for breakthrough symptoms.
12, 2016, Dr. LeFever assessed fibromyalgia, chronic pain
syndrome, basilar migraines, and mild but persistent asthma.
(Tr. 624). On examination, Plaintiff demonstrated lumbar
tenderness. (Tr. 625).
January 17, 2017, Plaintiff informed a nurse practitioner
that her migraines were “still about the same.”
November 21, 2011, Plaintiff saw Abra Morgan, PC, who noted
on mental status examination that Plaintiff was positive for
stuttering and flat affect. (Tr. 421-425).
January 27, 2015, Plaintiff saw Sarah Robinson, LISW, and
discussed issues related to chronic pain/medical issues. (Tr.
March 9, 2015, Plaintiff reported to social worker Robinson
that she would get overwhelmed in public. (Tr. 425). Ms.
Robinson wanted Plaintiff to leave her house more.
March 24, 2015, Plaintiff was seen by Heather Lewis, D.O.
(Tr. 527-532). On mental status examination, Plaintiff had an
anxious and depressed mood, constricted affect, tangential
thought process, and “limited-fair”
insight/judgment. (Tr. 528-529). Dr. Lewis diagnosed ...