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Title 38 relevant Migraine related VASRD section taken from July 1999:


MAGNUM, The National Migraine Association's Recommendation For Upgrading Title 38: Chapter I: Part 4: Section 4.124a: Sub-section 8100 Migraine's Rating to Reflect the Current Medical Understanding of Migraine Disease

Prepared for United States Senators Charles S. Robb, John W. Warner, and John McCain and other members of the Senate Arms Committee February 18th, 2000
By
Michael John Coleman, Executive Director & Founder
Terri Miller Burchfield, Legislative Director & Executive Vice President
Of
M.A.G.N.U.M., The National Migraine Association

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                                       Current Rating
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8100 Migraine:

With very frequent completely prostrating and prolonged attacks productive of severe
economic inadaptability....................................................................................................50

With characteristic prostrating attacks occurring on an average once a month over last
several months..................................................................................................................30

With characteristic prostrating attacks averaging one in 2 months over last several
months..............................................................................................................................10

With less frequent attacks..................................................................................................0

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                         Recommended New Revised Rating
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8100 Migraine:

With very frequent severe and completely prostrating and prolonged intractable
attacks productive of severe economic inadaptability......................................................100

With characteristic severe and prostrating attacks occurring on an average two to three times a month over last several months, or 8 to10 moderate attacks a month over last
several months..................................................................................................................60

With characteristic moderate to severe and prostrating attacks averaging one a month over last several months, or at least 2 moderate attacks per months over last several
months..............................................................................................................................30

A confirmed diagnosis of Migraine with a history of prostrating attacks..........................10

A confirmed diagnosis of Migraine with history of severe attacks......................................0

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Explanation of Fact Regarding Migraine as a Neurological Disease and it's Relationship to Epilepsy

       After careful consideration, and based upon the understanding that the Schedule for Rating Disabilities is to be revised upon better understanding of medical conditions contained within it's body, we present the following position to support the above-mentioned new rating structure for Title 38: Chapter I: Part 4: Section 4.124a: Sub-Section 8100 Migraine. According to the Department of Veterans Affairs, Title 38 was placed into law in 1945. To that fact, Sub-section 8100 has never been upgraded and is therefore based upon medical knowledge that is over 50 years old.

Migraine as a Neurological Disease

       In 1945, Migraine was not understood to be a neurological disease, but rather considered a personality disorder or a somatoform. According to the most widely used and accepted current medical findings, Migraines are not somatoform, are not psychogenic, and are not psychological. Migraine is, instead, an organic neurological disease. The New England Journal of Medicine1 reported specifically that "Studies of regional cerebral blood flow have helped clarify the biological basis of Migraine." The article goes on to say that "It is time for many practitioners of medicine to change their views and to acknowledge that Migraine is a neurobiologic, not a psychogenic, disorder."

       To further illustrate this fact, a separate peer reviewed paper published in the same prestigious medical journal featured a case study (there have been innumerable new case studies since that further solidify this point) that used positive-emission tomography to document the neurobiologic basis of Migraine disease. In this Journal article, Woods et al 2 confirmed previous studies of Migraine disease that identified regional cerebral blood flow and highlighted important new clinical observations. This study documented, as Olsen points out, "...beyond any reasonable doubt that spreading hypoperfusion is a real phenomenon. Most observations of regional cerebral blood flow in Migraine without aura have been normal, unlike those in Migraine with aura 3,4."

       Migraine is a disease of equal severity to and productive of equivalent economic inadaptability as other impairments on the Veterans Affairs Schedule for Ratings Disability (VASRD), such as Sub-section 8910 Epilepsy, grand mal (rate under the general rating formula for major seizures), and 8911 Epilepsy, petit mal (a thorough study of all material in Secs. 4.121 and 4.122 of the preface and under the ratings for epilepsy are listed as necessary prior to any rating action.) Hence the medically equivalent impairment is listed: Epilepsy. We suggest considering the fact that both Migraine and Epilepsy are convulsive disorders, and note that convulsive disorders, regardless of etiology and degree of impairment, the impairment should be determined according to type, frequency, duration, and sequelae of seizure (i.e. attacks). Based upon the close relationship between the two diseases, the Schedule for Rating Disabilities should use similar scale to rate the level of impairment. In addition, MAGNUM took under consideration comments regarding this suggested revision made by Dr. Carol McBrine, of the Department of Veteran Affairs, Office of Compensation & Pension Services.

The Relationship Between Migraine and Epilepsy

       Migraine and Epilepsy are interrelated in various ways. In medical terms, Migraine and Epilepsy are both disorders characterized by paroxysmal, transient alterations of neurologic function, usually with a normal neurologic examination between events. Both phenomena, when exaggerated due to excessive extracellular glutamate levels, may cause pathological effects such as hypersynchrony-Epilepsy and Spreading Depression (vascular)-Migraine. Biochemically, their traits are associated with increased plasma levels of glutamata, and current findings denote that both predispositions are associated with a tendency for an increase in extracellular glutamata levels. There is an almost universal finding of a familial or environmental predisposition towards both Epilepsy and Migraine. GABA levels and metabolism in the tissues are known to be high, low, or normal depending upon environmental circumstances. Both Migraine and Epilepsy react to environmental triggers (stimuli) of clinical hyperexcitation: strong, repetitive stimulus input, in the case of Epileptic seizures; and hypersensitive vasoconstrictive reaction to blood-born factor or light stimulus in the case of Migraine. Both diseases are forms of hypersynchronous excitation, and coincide with altered glutamate metabolism.

       The electrophysiological and neurochemical commonality between Migraine and Epilepsy has also been well established 5. Neurological clinics have noted that Epilepsy and Migraine can masquerade as each other, and in patients with Epilepsy or Migraine whose condition seems unclear, consideration of the other disorder may be warranted.

Seizures and Migraines 6

Migraine and seizures. The frequency of Migraine in an Epileptic population has been variably reported as 8.4% to 23% and the reported frequency of epilepsy in a Migraine population ranges from 1% to 17%. MELAS, arteriovenous, head trauma, and systemic lupus erythematosis can result in seizures and Migraines or Migraine like headaches. Migraine with typical or prolonged aura, basilar Migraine, and catamenial Epilepsy can be triggers for seizures. Migraine can cause a cerebral infarction which can cause seizures 7.

       Benign occipital Epilepsy, benign rolandic Epilepsy, and temporal and occipital lobe Epilepsy can cause seizures which mimic some features of Migraine. A seizure is more likely if the aura is less than 5 minutes and associated with alteration of consciousness, automatisms, and abnormal motor activity such as tonic-clonic movements. Migraine is more likely if the aura lasts more than 5 minutes and has positive (tingling, scintillations) and negative features (visual loss, numbness).

Ictal and postictal headaches. Hemicrania epileptica or synchronous ipsilateral ictal headache with Migraine features is a cause of headaches caused by a seizure. Most patients have both ictal headaches and some other seizure manifestations although ictal headaches can be the only symptom. The seizure discharges, usually on the same side as the ipsilateral headache, begin and end simultaneously with the headache. The headaches usually last a few seconds to minutes. Unilateral or bilateral headaches can occur during a temporal lobe seizure 8.

       Postictal headaches are common after partial complex and generalized tonic-clonic seizures, reported by 51% of subjects in one study 9. The headaches can be Migraine or tension like.

       Finally, it has been found that a chronic tendency for episodic seizures (Epilepsy) is considered to represent a severe neurological pathology which requires rather drastic pharmacological treatment. Chronic Migraine predisposition, in contrast, was until recently deemed to be an "unpleasant" but "benign" disease; pharmacological therapy, in general, mostly putative, has been far more cautious and many fewer side effects have been acceptable in the choice of drugs for treatment. Currently, there is no proficient pharmacological way to control Intractable Migraine as there is in Epilepsy. However, both the electrophysiological signs and, in particular, the neurochemical anomalies observed in Epilepsy and Migraine strongly suggest considerable similarities in the cascade of events culminating in clinical signs. It is not surprising, therefore, that one disorder may be mistaken for the other and that relationship between the two diseases has been postulated for over 100 years.

VASDR Sub-Section 8100 Migraine Revised

       Migraine and Epilepsy have been clearly shown to have specific clinical characteristics representing different aspects of the same impairing phenomenon. Thus, given the well-established physiologic arguments for a relationship between these two diseases, Migraine, specifically Intractable Migraine, can be determined to be medically equivalent to Epilepsy under the existing evaluation criteria. Even though a 100% or total disability rating would be possible in severe enough Migraine cases under the Total Disability Rating and Analogous Rating principles, the existence of established percentage ratings with a 50% disability maximum under Code 8100 discourages such findings in appropriate cases. The percentages and criteria for arriving at the same ought to be modified as suggested. Such revision would bring the VASRD current and allow for fair treatment of our servicemen and servicewoman suffering from Migraine disease.

 

1 Olesen J. Understanding the Biologic Basis of Migraine. The New England Journal of Medicine 1994: Vol 331:1689-92.

2 Woods RP, Iacoboni M, Mazziotta JC. Bilateral Spreading Cerebral Hypoperfusion During Spontaneous Migraine Headache. The New England Journal of Medicine 1994: Vol 331:1689-92.

3 Olsen J. Hemodynamics. In: Olsen J. Tfelt-Hansen P. Welch KMA, eds. The Headaches. New York: Raven Press. 1993:209-22.

4 Olsen J, Friberg L, Olsen TS, et al Timing and Topography of Cerebral Blood Flow, Aura, and Headache During Migraine Attacks. Ann Neurol 1990;28:791-8.

5 Epilep(tics) Have More Migraines. Columbia University Record ; February 10, 1995: Vol. 20, No. 16

6 Welch KMA, Lewis D. Migraine and epilepsy. Neurol Clin 15:107-123, 1997.

7 Marks DA, Ehrenberg BL. Migraine-related seizures in adults with epilepsy with EEG correlation. Neurology 1993;43:2476-2483.

8 Young GB, Blume WT. Painful epileptic seizures. Brain 106:537-554, 1983.

9 Schon F, Blau JN. Post-epileptic headache and Migraine. J Neurol Neurosurg Psychiatry 50:1148-1152, 1987.