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Angela M. v. Berryhill

United States District Court, D. Minnesota

April 5, 2019

Angela M. Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant.



         Pursuant to 42 U.S.C. § 405(g), Plaintiff seeks review of the Acting Commissioner of Social Security's (the “Commissioner”) denial of her application for disability insurance benefits (“DIB”). (ECF No. 4). The parties filed cross-motions for summary judgment. (ECF Nos. 15, 17). For the reasons set forth below, the Court denies Plaintiff's motion and grants the Commissioner's motion.

         I. BACKGROUND

         A. Procedural History

         Plaintiff filed for DIB on June 11, 2014, citing an alleged onset date of October 26, 2013. (Admin. R. at 98, 112, 117, ECF No. 14). Plaintiff alleged disability due to impairments of obesity, generalized anxiety with elements of panic, sleep apnea, carotid artery dissection, chronic headaches and migraines, fibromyalgia, Reynaud's disease, anemia, chronic subjective dizziness, restless leg syndrome, vasovagal syncope episodes, somatization disorder, irritable bowel syndrome, acid reflux, ADHD, major depressive order, and residual traumatic stress. (Admin. R. at 98-99, 102, 112-13). Plaintiff's claims were denied initially and upon reconsideration. (Admin. R. at 3, 12). Following a hearing, the administrative law judge (the “ALJ”) denied benefits to Plaintiff on March 29, 2017. (Admin. R. at 25). The Appeals Council denied Plaintiff's request for review, rendering the ALJ's decision final. (Admin. R. at 7). Plaintiff then initiated the instant lawsuit. (ECF No. 4).

         B. Factual Background

         The Court reviewed the entire Administrative Record but summarizes only the evidence necessary to determine the issues before the Court.


         Plaintiff has a long history of migraine headaches, beginning from age sixteen. (Admin. R. at 690). In March 1991, she underwent a resection of the left C1 lesion which proved to be a schwannoma.[1] (Admin. R. at 690). Between 1991 and 2015, Plaintiff had difficulty controlling her migraines and was on a variety of medications.[2] (Admin. R. at 690). In June 2010, the headache pattern changed and was associated with light and noise sensitivity as well as nausea. (Admin. R. at 690). She tried different medications but her headaches persisted. (Admin. R. at 690). In September 2010, Plaintiff's neurological exam showed right Horner syndrome but was otherwise normal.[3] (Admin. R. at 690). In January 2011, her condition improved as she had three or four headaches per month instead of a daily, continuous headache. (Admin. R. at 691). By May 2011, her headaches were under reasonably good control. (Admin. R. at 691).

         In September 2011, Plaintiff's headaches became more severe. (Admin. R. at 691). She had one headache lasting three days that caused her to take nine days off work and school. (Admin. R. at 691). She had an MRI and MRA of her head in the emergency room but neither showed any abnormalities. (Admin. R. at 691). In October 2011, she was experiencing a “continuous daily ‘dull headache'” with cervical and trapezius muscle pain. (Admin. R. at 691). Her neurological exam was normal and her doctor noted “good strength and reflexes, ” a normal gait, normal sensory exam, no muscle tenderness, but “limited volitional motor mobility of her neck and tenderness in both trapezius muscles.” (Admin. R. at 691). Plaintiff's doctor recommended a physiatrist. (Admin. R. at 691).

         In January 2012, Plaintiff continued to have neck pain radiating into her trapezius muscles and experienced pain in her right thigh and arm. (Admin. R. at 691). She also experienced imbalance and disequilibrium. (Admin. R. at 691). She had a normal neurological exam, aside from the partial right Horner syndrome which was long-standing. (Admin. R. at 691). Plaintiff's doctor noted “multiple tender points in the cervical and lumbar paraspinal muscles as well as the limbs.” (Admin. R. at 691). Her doctor recommended a visit to a fibromyalgia clinic along with a visit to a vestibular lab and a behavioral psychology clinic. (Admin. R. at 691). Plaintiff visited a vestibular lab, had a normal vestibular evaluation, and participated in vestibular rehab which she found helpful. (Admin. R. at 691-92). She also went to the Fibromyalgia Clinic but there are no notes on whether that was helpful. (See Admin. R. at 692).

         In August 2012, Plaintiff was “virtually headache-free.” (Admin. R. at 692). In March 2013, she had a particularly severe headache. (Admin. R. at 692). In May 2013, Plaintiff experienced daily headaches again but her neurological exam was normal. (Admin. R. at 692).

         In October of 2014, Plaintiff went to the doctor with complaints of a headache after fainting. (Admin. R. at 506-07). In the same month, she also had a CT scan of her head which did not show any hemorrhage, lesion, or infarction and only reflected changes from her earlier craniotomy. (Admin. R. at 520). Similarly, Plaintiff had an MRI scan of her head showing no acute intracranial abnormality. (Admin. R. at 405-09). Plaintiff's doctor recommended Botox injections to help with the headaches but Plaintiff testified she declined to try the Botox because the injections seemed “riskier.” (Admin. R. at 51-52, 496, 516).

         In February 2015, she had a normal neurological exam but continued to have headaches. (Admin. R. at 692). Plaintiff fell behind in her college courses because of her headaches. (Admin. R. at 692). In September of 2016, Plaintiff experienced headaches three to five days a week, which caused her to miss work as a receptionist. (Admin. R. at 692).

         2. Plaintiff's Medical Providers

         Dr. Beithon was Plaintiff's primary care physician and opined Plaintiff's impairments, including Plaintiff's headaches and other physical ailments, would preclude her from performing basic work activities and would require unscheduled breaks during an eight-hour day. (Admin. R. at 338). Dr. Beithon also opined Plaintiff would miss four or more workdays a month and would likely be off task for 25% of the time or more. (Admin. R. at 339).

         Ken Little was one of Plaintiff's therapists and treated her between 2009 and 2014. (Admin. R. at 452). He opined Plaintiff was unable to meet competitive standards and had no useful ability to function on most mental abilities and aptitudes needed to work. (Admin. R. at 454-55). Little stated Plaintiff could only handle simple tasks in short segments and noted a number of physical symptoms in his findings such as fibromyalgia pain and frequent, incapacitating pain. (Admin. R. at 455-56). Little reported Plaintiff had problems managing daily routines and fell behind in her college classes because of her anxiety and mental state. (Admin. R. at 457-59). Little opined Plaintiff would miss more than four days a month of work because of her physical and mental impairments. (Admin. R. at 456).

         Dr. Hal Baumchen, another therapist, evaluated Plaintiff for psychological difficulties and depression. (Admin. R. at 747). In a December 2013 report, he stated Plaintiff had severe depression, signs of emotional distress, poor concentration, post- traumatic stress nightmares and flashbacks, difficulties in concentration and attention, negative expectations, and confusion. (Admin. R. at 747-52).

         Greg Walsh, a licensed social worker, also saw Plaintiff for mental health treatment. (Admin. R. at 755-59). Walsh opined that Plaintiff did not have the limited abilities or aptitudes necessary for unskilled or skilled work. (Admin. R. at 757-58). Walsh stated Plaintiff would miss more than four days of work per month because of her impairments. (Admin. R. at 759).

         3. ...

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