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Thomas v. Colvin

United States District Court, W.D. Pennsylvania

July 2, 2015



TERRENCE F. McVERRY, District Judge.

I. Introduction

Nicole Marie Thomas ("Plaintiff") brought this action for judicial review of the decision of the Acting Commissioner of Social Security ("Acting Commissioner"), which denied her applications for disability insurance benefits ("DIB") under Title II of the Social Security Act ("Act"), 42 U.S.C. §§ 401-403, and supplemental security income ("SSI") under Title XVI of the Act, 42 U.S.C. §§ 1381-1383(f). Now pending before the Court are the parties' cross-motions for summary judgment (ECF Nos. 8, 10), which have been fully briefed (ECF Nos. 9, 11) and are ripe for disposition. For the following reasons, Plaintiff's motion will be GRANTED, and the Acting Commissioner's motion will be DENIED.

II. Background

Plaintiff was born on October 10, 1978.[1] (R. 44). She is married and does not have any biological children; however, she has three stepchildren. (R. 45). She graduated from high school and completed a few college courses. (R. 47, 208). She has past relevant work experience as a cashier, kennel attendant, still photographer, shift manager, waitress, fast food worker and retail cashier/stocker. (R. 33). However, she has not engaged in substantial gainful activity since her alleged onset date of June 13, 2009. (R. 18). This appeal relates to the assessment of Plaintiff's migraine headaches, so the Court will only recount the medical evidence as it relates to that condition.

A. Medical Evidence

Plaintiff testified that she stopped working as a portrait studio photographer in 2009, mainly due to "getting my migraines at the time, " though she also had an issue with her hand that caused her to drop objects. (R. 50). According to Plaintiff, her migraines "dictate" her life. (R. 60). They occur on a weekly basis and can last two to three days at a time, requiring her to lie down for four to five hours. (R. 60). On bad days, she spends the entire day in bed. (R. 59, 65). Noise and light made things worse, to the point that Plaintiff has installed "blackout" curtains in her bedroom. (R. 60). She testified that when she worked at Wal-Mart, she took Family and Medical Leave Act Leave due to her migraines because she could not work through them. (R. 61).

Although Plaintiff apparently has a long history of migraines, they are not referenced in the medical evidence until April 10, 2012. (R. 623). On that date, Plaintiff called her primary care physician Dr. Kreig A. Spahn's office to tell him that she had been experiencing a migraine for a few days. On June 18, 2012, Plaintiff presented for a follow-up visit with Dr. Spahn regarding lumbago and hypertension. (R. 618). His treatment notes stated that Plaintiff was feeling better, but no mention was made of migraines. (R. 617). Two months later, on August 7, 2012, records from Dr. Spahn indicate that Plaintiff was restarted on Nortipryline to treat her lumbago.

Plaintiff phoned Dr. Spahn's office on August 16, 2012, requesting a prescription for Fiorcet for her migraines. (R. 613). She had previously been prescribed this medication, but not since 2008 or 2009. Id. On August 24, 2012, Plaintiff followed up with Dr. Spahn with regard to her migraines. (R. 610). She reported that she experienced three headaches a month, each of which lasted four days. Id. The headaches were accompanied by nausea, vomiting, photophobia, and phonophobia, but Plaintiff said that Fiorcet helped to "take the edge off." (R. 610). On August 28, 2012, however, Plaintiff phoned Dr. Spahn's office stating that Fiorcet was not helping. (R. 609). She was told to wait two days, and advised that she might need to change medication if the migraines persisted. Id.

Plaintiff next saw Dr. Spahn on September 11, 2012. (R. 607). She reported that the Fiorcet was not working, so she began using more Vicodin than prescribed. Id. Nontheless, the headache still lasted a couple weeks, though it had resolved prior to her appointment. Id. Dr. Spahn noted that Plaintiff's migraines were "suboptimally controlled." (R. 608). He started her on Imitrex, adjusted her dosage of Nortiptyline, and instructed her to follow up in a month. Id.

On September 13, 2012, Plaintiff underwent a CT scan without contrast at the behest of Dr. Spahn. (R. 574). Sequential noncontrasted tomographic images were obtained from the skull base to the high convexity of the head. Id. The findings were unremarkable with no hemorrhage or mass depicted. Id.

On November 13, 2012, Plaintiff presented to Dr. Spahn for an evaluation of her migraines. (R. 605). Treatment notes state that the headaches were occurring in an "increasing pattern" - up to "a couple times a week." Id. Plaintiff stated that she would wake up with "full blown" headaches and vomiting. Id. In the assessment section of the record, Dr. Spahn noted that Plaintiff's migraines were again "suboptimally controlled." (R. 606). He continued Plaintiff on Celexa and increased her prescription of Nortriptyline HCI from one capsule to three capsules every night. (R. 606, 607).

On December 14, 2012, Plaintiff returned to Dr. Spahn, complaining that her pain medications were no longer helping control her migraines. (R. 602). She reported that she would still awake with migraines, accompanied by vomiting. Id. Once again, Dr. Spahn noted that the migraines were "suboptimally controlled, " so he decreased Nortriptyline HCI from three capsules to two capsules every night. (R. 604, 606).

On February 12, 2013, Plaintiff met with Dr. Colantonio for a follow-up regarding her hand pain. (R. 579). She stated during that visit that her headaches were somewhat better. Id. Plaintiff had another follow up with Dr. Colantonio on April 16, 2013, in ...

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