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Martin v. Berryhill

United States District Court, N.D. Ohio, Eastern Division

September 4, 2019

NANCY A. BERRYHILL, Acting Comm'r of Soc. Sec., Defendant.


          David A. Ruiz, United States Magistrate Judge.

         Plaintiff, 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.

         I. Procedural History

         On 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).

         Plaintiff 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).

         II. Evidence

         A. Relevant Medical Evidence [1]

         1. Treatment Records

         On 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).

         On December 21, 2012, Dr. Lamkin referred Plaintiff for additional evaluation and indicated her visual fields show severe constriction. (Tr. 587).

         On 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. 696).

         On 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.

         On 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. Id.

         On May 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.

         On October 25, 2013, Dr. LeFever assessed diabetes mellitus uncontrolled, fibromyalgia, obesity, anxiety, hyperlipidemia, and lumbago, but omitted migraines, headaches, and vertigo. (Tr. 677).

         On 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).

         On June 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).

         On July 3, 2014, Dr. Espiritu observed decreased left lower extremity motor strength on examination. (Tr. 349-350).

         On July 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).

         On July 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.

         On 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).

         On November 18, 2014, Dr. LeFever assessed sinusitis and fibromyalgia. (Tr. 390). He noted Plaintiff recently saw a neurologist who increased her Topamax prescription. Id.

         On 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.” (Tr. 881).

         On July 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. Id.

         On July 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).

         On January 17, 2017, Plaintiff informed a nurse practitioner that her migraines were “still about the same.” (Tr. 878).

         b. Mental Impairments

         On 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).

         On January 27, 2015, Plaintiff saw Sarah Robinson, LISW, and discussed issues related to chronic pain/medical issues. (Tr. 428).

         On 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. Id.

         On 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 ...

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