Disability:

MAGNUM's Draft Legislation

Medical & Political Justification

Medical Evaluation Criteria For The Migraine Disease

RE: Disability Evaluation Criteria Under Social Security Parts A & B

'Listing Of Impairments'

Section 11.00 Neurological 11.01 Category Of Impairments

New Sub-Section: 11.20 Migraine

THE DISABILITY EVALUATION UNDER SOCIAL SECURITY HAS BEEN SPECIALLY PREPARED TO KEEP PHYSICIANS AND OTHER HEALTH CARE PROFESSIONALS UP TO DATE WITH THE LATEST CHANGES IN THE DISABILITY PROGRAM (TITLE II OF THE SOCIAL SECURITY ACT) AND THE SUPPLEMENTAL SECURITY INCOME PROGRAM (TITLE XVI OF THE SOCIAL SECURITY ACT).

Prepared By Michael John Coleman and Terri Miller Burchfield of MAGNUM: The National Migraine Association for United States Senator John Warner (R-VA) & Congressman James P. Moran (D-VA). Originally prepared for and supported by former Senator Charles S. Robb (D-VA)

In keeping with the spirit of revising and making available periodically the Listing of Impairments, we hereby submit the following current understanding of Migraine disease and recommended addition to the Disability Evaluation Criteria Under the Social Security Act Listing of Impairments, namely new Sub-Section 11.20 Migraine

New technology and breakthroughs over the past decade in neurogenic theory of Migraine have advanced recent drug development for Migraine disease treatment. A consensus has developed that Serotonin (5-Hydroxytryptamine or 5-HTT) plays a key role in Migraine and that Migraine is a true organic illness, not a psychological disorder triggered by stress or depression. The FDA (Food and Drug Administration) has approved drugs designed specifically to treat Migraine disease, although these drugs are designed for the management of symptoms only, i.e., are not a cure. Recently, after several years of clinical studies, the FDA has approved several existing anti-epileptic drugs for Migraine prophylactic treatment, demonstrating the pharmaceutical industry's continued commitment and recognition of this disease. "There are billions of dollars being spent on Migraine research..." noted Dr. Stephen D. Silberstein, co-director, Comprehensive Headache Center, Philadelphia.

Medical Equivalency

Under the guidelines set forth in the Social Security Administration (SSA) publication no. 05-10029 and related documents, Migraine is a disease 'of equal severity to impairments on the list,' and should therefore under the guidelines be included on the Listing of Impairments . The medically equivalent impairment is listed under 11.01 Category of Impairments; Neurological; Sub-Sections 11.02 and 11.03; Epilepsy. The parameters set forth in Section 11.00; Neurological; Sub-paragraph A); Convulsive Disorders, state: "In convulsive disorders, regardless of etiology degree of impairment, the impairment will be determined according to type, frequency, duration and sequel of seizures" (i.e. attacks).

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. 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.

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 the past decade 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. To that fact, in the past two years the FDA has approved two anti-convulsive Epilepsy drugs for Migraine prevention therapy. 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.

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 can be determined to be medically equivalent to Epilepsy under the existing evaluation criteria.

It should also be noted that Migraine is currently recognized by the U.S. government as a disability in the Veterans Affairs Schedule for Ratings Disability (V.A.S.R.D.) under Miscellaneous Disease Section 8100: Migraine. So severe is Migraine that the Pentagon concurred with MAGNUM and recently upgraded the V.A.S.R.D. from a maximum 50% disability rating to the current rating of up to 100% for Migraine disease.

In 2001, President Bush issued a policy letter at the Tenth Annual International Headache Congress (Migraine and head-pain disorders) recognizing Migraine disease and headache disorders as a major American public health issue. In addition, at the XI International Headache Congress in Rome, Italy in 2003, Secretary of Health and Human Services Tommy Thompson acknowledged the global burden of Migraine disease and headache disorders and commended the efforts of the medical congress.

Furthermore, on a global scale, Migraine disease was acknowledged by a World Health Organization (WHO) blue book report that was issued in London at the Headache 2000 International Medical Congress. This report was the result of an official Meeting on Headache and Related Disorders, held at the WHO Headquarters, Geneva, Switzerland, in March 2000. MAGNUM was proud to be the Non-Government Organization (NGO) representing the United States at this critical international meeting. This report lead to an additional 2003 WHO blue report recognizing Migraine as one of the worlds top twenty most disabling diseases.

Conclusion

Addressing this burdensome oversight in the Federal Disability Evaluation Criteria under Social Security Parts A & B 'Listing Of Impairments' is the right thing to do. Americans who have paid into the Medicare system who are properly diagnosed with episodic disabilities such as Migraine disease, deserve appropriate access to Social Security Disability if they are medically qualified and meet the criteria. If upon reviewing this document the Department of Health & Human Services acts to adjust this regulation to reflect the most current scientific understanding of Migraine disease Congress will not have to act.
 

Suggested Criteria

11.20 MIGRAINE-with very frequent completely prostrating and prolonged attacks occurring more frequently than 2 to 3 times a month. Documented by a history of episodes and by a detailed description of a typical attack, with pattern and various associated phenomena.
 

¹ Disability Evaluation Under Social Security: Blue Book- January 2005 (Most current SSD Blue Book)
² WHO/MSD/MBD/00.9: Headache Disorders & Public Health/Neurological Diseases and Neuroscience Issued September 2000.
³ The Global Burden of Disease (GBD)/Epidemiology & Burden of Disease/Who Health Organization Report issued in Geneva 2003.

11.01CIN11.20rev94;052506

MAGNUM Draft Legislation in PDF format (requires free Adobe Acrobat Reader)