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Martinez v. Berryhill

United States District Court, D. New Mexico

March 30, 2018

NANCY A. BERRYHILL, [1] Acting Commissioner of the Social Security Administration, Defendant.


         THIS 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 income. Doc.

         19. The Court concludes that the ALJ did not err in his consideration of Plaintiff's headache disorder. Therefore, the Court will deny Plaintiff's motion.

         I. BACKGROUND

         Plaintiff 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.

         Because Plaintiff's arguments concern the ALJ's consideration of her headache disorder, the Court only sets forth the relevant background regarding this particular impairment.

         A. Relevant Medical History

         Plaintiff 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.

         Plaintiff's 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. AR 454-55.

         Approximately 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.

         Approximately 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.

         Shortly 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. Id.

         At the 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.[2] AR 18.

         B. Procedural History

         On July 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.[3] 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 ...

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