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Loude v. Berryhill

United States District Court, E.D. Arkansas, Helena Division

January 8, 2018

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration DEFENDANT


         Plaintiff Crystal Loude (“Loude”) began this case by filing a complaint pursuant to 42 U.S.C. 405(g). In the complaint, she challenged the final decision of the Acting Commissioner of the Social Security Administration (“Commissioner”), a decision based upon the findings of an Administrative Law Judge (“ALJ”).

         Loude maintains that the ALJ's findings are not supported by substantial evidence on the record as a whole.[1] It is Loude's contention that the ALJ gave inadequate reasons for discounting the opinions of Dr. Kenneth Chan, D.O., (“Chan”), Loude's treating physician, with respect to Loude's migraine headaches.

         The record reflects that Loude was born on November 10, 1979, and was thirty-five years old when she filed her application for supplemental security income payments on February 5, 2015. She alleged in the application that she became disabled as a result of, inter alia, her migraine headaches.

         The ALJ is required to assess the claimant's residual functional capacity, which is a determination of “the most a person can do despite that person's limitations.” See Brown v. Barnhart, 390 F.3d 535, 538-39 (8th Cir. 2004). The assessment is made using all of the relevant evidence in the record, but the assessment must be supported by some medical evidence. See Wildman v. Astrue, 596 F.3d 959 (8th Cir. 2010). In making the assessment, the ALJ is required to consider the medical opinions in the record. See Wagner v. Astrue, 499 F.3d 842 (8th Cir. 2007). A treating physician's medical opinions are given controlling weight if they are well-supported by medically acceptable clinical and laboratory diagnostic techniques and are not inconsistent with the other substantial evidence. See Choate v. Barnhart, 457 F.3d 865 (8th Cir. 2006). The ALJ may discount a treating physician's medical opinions if other medical assessments are supported by better or more thorough medical evidence or where the treating physician renders inconsistent opinions that undermine the credibility of his opinions. See Id.

         The ALJ must evaluate the claimant's subject iv e com pla i nt s a s a p a rt o f a s se s si n g his residual functional capacity. See Pearsall v. Massanari, 274 F.3d 1211 (8th Cir. 2001). The ALJ does so by considering all of the evidence, including the following:

... [the] objective medical evidence, the claimant's work history, and evidence relating to the factors set forth in Polaski v. Heckler, 739 F.3d 1320, 1322 (8th Cir. 1984): (i) the claimant's daily activities; (ii) the duration, frequency, and intensity of the claimant's pain; (iii) precipitating and aggravating factors; (iv) the dosage, effectiveness, and side effects of medication; and (v) the claimant's functional restrictions. ... An ALJ need not expressly cite the Polaski factors when ... [he] conducts an analysis pursuant to 20 C.F.R. 416.929 because the regulation “largely mirror[s] the Polaski factors.” Schultz v. Astrue, 479 F.3d 979, 983 (8th Cir. 2007); see 20 C.F.R. 416.929(c)(3)(i)-(iv), (vii) (2011) ...

See Vance v. Berryhill, 860 F.3d 1114, 1120 (8th Cir. 2017).

         A summary of the evidence relevant to Loude's migraine headaches reflects that on October 11, 2013, she presented to Dr. James Beaton, M.D., (“Beaton”) complaining of cold symptoms and low back pain. See Transcript at 473-475. During the course of the examination, she complained of migraine headaches. He credited her self-report and diagnosed migraine headaches. He recommended Topamax and referred her to Chan, a neurologist, for an evaluation of the headaches.

         Beginning on January 18, 2014, and continuing through February 19, 2014, Loude sought treatment from a chiropractor on nine occasions. See Transcript at 292-297. The chiropractor's progress notes are relevant to Loude's migraine headaches because she repeatedly denied headaches but complained of pain in her neck, shoulders, arms, back, hips, and legs.

         On March 13, 2014, Loude presented to Beaton complaining of a migraine headache. See Transcript at 350-351. He recorded her history of present illness and noted the following:

MS. LOUDE presents with classic migraine. [She] was diagnosed with migraine headaches > [i.e., greater than or more than] 10 years ago. Typical precipitating factors include lack of sleep. The current headache began approximately two weeks ago. The location is primarily left temporal and frontal. The pain radiates to the neck. She characterizes the headache as moderate in severity and throbbing. Associated symptoms include sinus congestion, vision disturbance (scotoma) and vomiting. She denied fever. She has been taking Topamax, 100 mg q hs. She has been taking Relpax in the last week without improvement.

See Transcript at 350. Beaton recorded Loude's medications to include Relpax and Topamax. He diagnosed migraine headaches without aura and prescribed medications that included Toradol, Phenergan, and Ondansetron.

         Chan saw Loude on March 31, 2014, for her migraine headaches. See Transcript at 382-384. He noted that Topamax had reduced the number of her headaches by about fifty percent. She had, though, experienced a headache that persisted for one week. He diagnosed a migraine headache and prescribed Topiramate. He ordered an MRI of her brain, the results of which were normal. See Transcript 380.

         Chan saw Loude again on November 7, 2014, and noted that she continued to experience migraine headaches. See Transcript at 377-378. He increased her dosage of Topamax and prescribed Imitrex. He also ordered an EEG and a twenty-four hour Holter monitor.

         On November 29, 2014, Loude was visiting her family in Detroit, Michigan, when she sought emergency care for her complaints of migraine headaches and episodes of syncope. See Transcript at 315-332. Her history of present illness was recorded to include the following:

... [Loude] has long history of migraine headaches since teenager, usually she has migraine[s] with aura characterized by flashing light and sometimes ... severe bilateral headache[s]. She lately has daily headaches. ... They just increased Topamax to 200 milligrams twice a day. She just started with the ...

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