United States District Court, D. New Mexico
LOUANA M. MARTINEZ, Plaintiff,
NANCY A. BERRYHILL,  Acting Commissioner of the Social Security Administration, Defendant.
MEMORANDUM OPINION AND ORDER DENYING PLAINTIFF'S
MOTION TO REMAND
MATTER is before the Court on Plaintiff Louana
Martinez's Motion to Reverse and Remand the Social
Security Commissioner's final decision denying
Plaintiff's applications for a period of disability,
disability insurance benefits, and supplemental security
Court concludes that the ALJ did not err in his consideration
of Plaintiff's headache disorder. Therefore, the Court
will deny Plaintiff's motion.
filed a Title II application for a period of disability and
disability insurance benefits on August 17, 2014 and a Title
XVI application for supplemental security income on February
5, 2015. Administrative Record (“AR”) 103-104.
She alleged a disability onset date of August 17, 2014. AR
18. After her claim was denied on initial review and upon
reconsideration, her case was set for a hearing in front of
an ALJ on June 27, 2016. Id.
Plaintiff's arguments concern the ALJ's consideration
of her headache disorder, the Court only sets forth the
relevant background regarding this particular impairment.
Relevant Medical History
testified during the hearing before the ALJ that her
headaches began after she was in a car accident in March
2013. AR 41. Plaintiff stated that she sought treatment for
the headaches following the accident, which included seeing a
chiropractor. AR 40-41. After the accident, Plaintiff
continued working full-time throughout 2014 and a few months
into 2015. Id. She testified that she ultimately
stopped working due to the headaches and indicated that she
can no longer work full-time because the “headaches are
very debilitating.” AR 40, 44.
medical records show that on September 11, 2015, she sought
treatment from Dr. Barbara Bath, M.D. for recurring migraine
headaches. AR 443-447. Plaintiff reported to Dr. Bath that
the severity of the headaches was moderate, that the
headaches were recurring in nature and affected her entire
head, and that they were alleviated by darkness,
over-the-counter medicines, and herbal oil on neck. AR 443.
Plaintiff also reported symptoms of dizziness, nausea,
phonophobia, photophobia, and neck stiffness associated with
the headaches. Id. Dr. Bath diagnosed Plaintiff with
headache disorder and prescribed Amitriptyline to treat the
headaches. AR 448. Dr. Bath also advised Plaintiff to take
Ibuprofen as needed for the headaches and scheduled a
follow-up appointment in one month. Id. At this
follow-up appointment on November 12, 2015, Plaintiff
reported improvement in her condition and further indicated
that Amitriptyline was helping with the migraine headaches.
AR 452-54. This improvement in her condition was reflected in
her reporting to Dr. Bath that she no longer had nausea,
phonophobia, photophobia, neck stiffness, vertigo, or
diplopia symptoms in connection with the headaches. AR 452.
Dr. Bath advised Plaintiff to continue taking Amitriptyline.
six months after seeing Dr. Bath, Plaintiff sought treatment
for her headaches from another provider, Dr. Vanessa
Licona-Sanjuan, M.D. AR 496. At her initial visit on May 24,
2016, Plaintiff indicated to Dr. Licona-Sanjuan that the
headaches were moderate to severe in nature, occurred daily,
and lasted at least one hour in duration. Id.
Plaintiff described the headaches as a “throbbing
sensation aggravated by noise, stress, light” and
associated with “blurry vision, dizziness, [and]
tingling involving both hands.” Id. Plaintiff
reported to Dr. Licona-Sanjuan that she had taken
Amitriptyline for the headaches the previous year which
resulted in an “improvement of the intensity and
frequency of headaches.” Id. Dr.
Licona-Sanjuan directed Plaintiff to start taking
Amitriptyline at the previously prescribed dosage, 25 mg, and
if tolerated for five days, to double the dose to 50 mg. AR
498-99. Dr. Licona-Sanjuan also prescribed Prednisone, Maxalt
and/or Naproxen, as needed for the headaches. Id.
one month after her appointment with Dr. Licona-Sanjuan,
Plaintiff appeared for the June 27, 2016 hearing before the
ALJ. At the hearing, Plaintiff testified that her headaches
occur on a daily basis, last all day, and she gets
“little relief” from the medications she takes
for the headaches. AR 45-46. Plaintiff indicated that during
a headache she has to isolate herself, stay away from bright
lights, stay in a room with air conditioning, avoid noise,
and use heat or cold packs. AR 46-47. Plaintiff testified
that her pain level due to the headaches is 9 out of 10 on a
daily basis, even with the use of medication. AR 47.
Plaintiff also testified that the headaches make it difficult
to do household chores and she requires assistance from her
family. AR 48. Plaintiff further indicated that she stays in
bed all day “maybe two times a week” due to the
headaches. AR 48-49.
after the hearing, on July 6, 2016, Plaintiff saw Dr.
Licona-Sanjuan for a follow-up evaluation of her headaches.
AR 492. Plaintiff reported “significant improvement of
frequency and intensity” of her headaches as a result
of the increased dosage of Amitriptyline. Id. Dr.
Licona-Sanjuan directed Plaintiff to continue taking
Amitriptyline, and added another medication, Sumatriptan, to
be taken as needed for migraines. AR 494. Plaintiff was also
directed to follow-up with Dr. Licona-Sanjuan in one year.
time of the hearing before the ALJ, Plaintiff's records
from her initial visit with Dr. Licona-Sanjuan were not part
of the administrative record. The ALJ, however, kept the
record open for 15 days to allow Plaintiff to submit any
additional medical records. AR 18. The ALJ stated in his
written decision that he did not receive any additional
medical records prior to issuing his decision. AR 18.
20, 2016, the ALJ issued a written decision finding that
Plaintiff was not disabled within the meaning of the Social
Security Act. AR 18-29. In arriving at his decision, the ALJ
determined that Plaintiff had not engaged in substantial
gainful activity since August 17, 2014, her alleged onset
date. AR 20-21. The ALJ then found that
Plaintiff suffered from the following severe impairments: (1)
headache disorder; (2) posttraumatic stress disorder; (3)
anxiety; and (4) depression. AR 21. The ALJ determined that
Plaintiff's remaining impairments were non-severe. AR 21.
Further, with regard to the severe impairments, the ALJ ...