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Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Migraine Headache


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Ability to Work | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
346.00 - Migraine, Classical, without Mention of Intractable Migraine
346.01 - Migraine with aura, with intractable migraine, so stated, without mention of status migrainosus
346.10 - Migraine, Common, without Mention of Intractable Migraine
346.11 - Migraine without aura, with intractable migraine, so stated, without mention of status migrainosus
346.20 - Variants of Migraine without Mention of Intractable Migraine
346.21 - Variants of migraine, not elsewhere classified, with intractable migraine, so stated, without mention of status migrainosus
346.80 - Migraine Headache without Mention of Intractable Migraine, Other Forms
346.81 - Other Forms of Migraine, with Intractable Migraine, So Stated, without Mention of Status Migrainosus
346.90 - Migraine Headache, Unspecified, without Mention of Intractable Migraine
346.91 - Migraine, unspecified, with intractable migraine, so stated, without mention of status migrainosus

Related Terms

  • Classical Migraine Headache
  • Common Migraine Headache
  • Migraine Headache with Aura
  • Migraine Headache without Aura

Overview

Migraine is a type of headache characterized by narrowing (constriction) of vessels in the brain, followed by painful dilation and inflammation of the same blood vessels. It is described as a "sick headache," not only because there may be nausea and vomiting, but also because the individual typically feels completely disabled throughout the duration of the headache.

The pain is moderate to severe, throbbing or pulsating, and usually localized to one side of the head. Migraines can last from hours to days, and may also be associated with sensitivity to light and sound. The headaches can be preceded by an aura or warning symptoms related to the blood vessel narrowing and may include visual disturbances, limb numbness, tingling, or hyperactivity. Migraine with aura is a classification that represents 20% of migraine headaches. A designation of migraine without aura, representing about 80% of all migraines, has replaced the former classification of common migraine (Blanda).

In the mid-twentieth century, migraine was believed to be only vascular in origin, but the pathophysiology is explained today as a complex interaction of neural and vascular events (neurovascular theory) (Sahai-Srivastava). A state of hyperexcitability of neurons in the cerebral cortex of the brain has been demonstrated through MRI studies of the aura that precedes migraine. In migraine with aura, the trigger is a wave of neuron excitation in the gray matter of the cortex (cortical gray matter), followed by a wave of neuron suppression. Blood vessels in the cortex constrict and dilate corresponding to these waves. This pre-migraine process is referred to clinically as cortical spreading depression. The reason this process occurs in some individuals is not fully understood.

Coexisting medical conditions such as seizures, sleep disorders, high blood pressure (hypertension), and depression may be associated with migraine. Migraines may also be triggered or made worse by certain foods (chocolate, aged cheeses, peanuts, red wine, food additives [monosodium glutamate (MSG), nitrates]), alcohol, insufficient sleep, stress, and hormonal changes associated with the menstrual cycle.

Incidence and Prevalence: In the United States, headache affects 60% to 80% of all individuals; an estimated 10% to 20% of the population suffers from migraine headaches. Frequency of headaches varies greatly by individual. About 6% of men and 15% to 17% of women in the United States have migraine, making it the second most common type of headache syndrome in the United States; the most common are tension headaches (Blanda).

In the United States, white women have the highest incidence of migraine, and Asian women have the lowest incidence (Sahai-Srivastava).

Source: Medical Disability Advisor



Causation and Known Risk Factors

About 70% of patients have a first-degree family member with a history of migraine. Among adults, women are at greater risk than men, with a female-to-male ratio of 3:1 (Blanda). Before puberty, migraines occur more often in males (Blanda). The age of onset varies but most commonly occurs by age 30; migraines are rare in individuals older than 50 (Blanda).

Source: Medical Disability Advisor



Diagnosis

History: Individuals may report symptoms associated with the headache, such as nausea, vomiting, pale skin, dizziness, or sensitivity to light (photophobia) and sound (sonophobia). The individual should be questioned about duration, location, pulsating quality, intensity, presence of aura, and frequency of headaches. Visual disturbances account for most symptoms that may be associated with the aura, including bright spots resembling stars, sparks, geometric patterns, or lightning bolts (fortification spectra). When the bright spots disappear, blind spots (scotoma) or decreased vision may follow. Other symptoms associated with the aura may include numbness, especially of the hand and lower face. Weakness, clumsiness, or speech disturbances are less common. The aura usually lasts about 30 minutes, followed by a brief period of normalcy before the headache begins.

Some individuals may report behavioral changes before or after attacks, that include depression, anxiety, irritability, excitability, or a change in sexual appetite. Identifying possible triggers may help distinguish migraine from headache caused by other disorders such as a brain tumor. Investigating family history and obtaining details of previous headaches may be essential to the diagnosis.

Physical exam: The exam may reveal no specific findings, or may reveal abnormalities such as recent head or neck trauma and muscle spasms that can help establish diagnosis and aid in selecting treatment. The presence of systemic symptoms such as myalgia, fever, weight loss, scalp tenderness, or jaw pain while eating may indicate a more serious cause of headache. Neurological examination includes evaluation of brain and nerve function, sensory discrimination, reflexes, strength, coordination, and cognitive abilities. Eye examination may reveal neurologic disease, diabetes, high blood pressure (hypertension), and other coexisting medical conditions. Confusion, seizures, impaired consciousness, balance problems, weakness, or paralysis that may occur temporarily during the headache suggest a migraine variant (e.g., vertebrobasilar migraine, status migrainosus, ophthalmoplegic migraine) (Sahai-Srivastava).

Tests: Tests are performed to rule out other possible causes of headache, such as a brain tumor or cerebral aneurysm. Imaging studies (CT or MRI) may reveal brain abnormalities that can mimic migraine. Neuro-imaging is only warranted if the neurologic examination reveals abnormalities. If the individual's history suggests seizures, a test of the brain's electrical activity (electroencephalogram, or EEG) may help diagnose epilepsy that may coexist with migraine. These cases are rare, and therefore the tests are not routinely done unless warranted by history and physical examination findings. Spinal fluid may be sampled (lumbar puncture, or LP) to test for infection or hemorrhage. Laboratory tests may also be done if an underlying organic condition is suspected.

Source: Medical Disability Advisor



Treatment

Treatment is aimed at reducing the severity, frequency, and duration of attacks. During a sudden (acute) episode, it may help the individual to rest in a quiet, darkened room. The main classes of drugs available to treat acute migraine are agents that narrow blood vessels (triptans, ergotamines), and non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium, ibuprofen, ketoprofen, or ketorolac. Pain killers (analgesics) such as acetaminophen or aspirin can relieve mild to moderate migraine. Combination painkillers that contain codeine or caffeine may be helpful.

Once the headache is underway, treatment usually requires a drug that narrows the opening of blood vessels (vasoconstrictor) to stop the attack. These medications (e.g., ergot alkaloid) are most helpful if given during the aura. With the availability of new types of vasoconstrictor taken by mouth or injection (triptans), pain relief may begin within a few minutes. If nausea and vomiting occur, medication may have to be administered under the tongue, by injection, or rectally. Migraine attacks that are severe, prolonged, or unresponsive to self-administered medications may have to be treated in the doctor's office or emergency room.

Prevention of migraine is an important part of treatment. Avoiding precipitating factors may decrease the frequency of acute episodes. If episodes occur more than 2 or 3 times a month, a variety of drugs can be taken for prevention, including agents that lower blood pressure (beta-blockers, calcium antagonists), anticonvulsants, tricyclic antidepressants, an agent that narrows openings of blood vessels and prevents inflammatory responses (methysergide), and agents that inhibit release of certain chemicals in the brain (selective serotonin reuptake inhibitors, or SSRIs). The individual may have to try several different drugs, one at a time, before the headaches are brought under control. Naproxen sodium has also been used for short-term prevention of migraine, especially menstrual migraine. Drug combinations may be used for individuals who do not respond to a single therapy. Beta-blockers and antidepressants may be used together. Once an effective drug or combination is found, it should be continued for at least 6 months and then tapered off after the disappearance of headaches. Medication for acute episodes may be occasionally used with preventive medication if breakthrough headaches occur (e.g., menstrual migraine).

Source: Medical Disability Advisor



Prognosis

Occasionally, migraine headaches may spontaneously disappear, especially as individuals reach middle age. Self-care is very important, and the migraine sufferer can increase the chance of successful outcome by taking medications as directed by the doctor and modifying lifestyle factors such as diet, exercise, avoidance of migraine triggers, stress management, and proper rest. Any changes in headache frequency or severity should be communicated to the doctor, and treatment should be adjusted to improve the outcome.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Family Physician
  • Internal Medicine Physician
  • Neurologist

Source: Medical Disability Advisor



Comorbid Conditions

  • Cardiovascular disease
  • Endocrine disorders
  • Neurologic conditions (e.g., epilepsy)
  • Psychiatric disorders

Source: Medical Disability Advisor



Complications

Migraine sufferers are more prone to develop tension-type headaches that result in mixed headache syndrome. Excessive use of painkillers may cause rebound headaches when the drug's effects wear off, and episodic headaches may be transformed into chronic daily headaches. Acetaminophen alone or with codeine can increase toxicity in individuals who also take antidepressants; regular alcohol consumption combined with acetaminophen usage may result in liver toxicity (hepatotoxicity) (Blanda). Coexisting medical conditions may complicate the disorder by limiting treatment options. Many medications used to treat headaches affect the cardiovascular system. The relative risk of thrombotic stroke may be higher in women with migraine. Stroke risk in migraine sufferers is further increased by smoking or by the use of birth control pills. Migraine may also be associated with epilepsy or depression. Many individuals (up to 50%) discontinue their treatment regimen because they have not been satisfied with the results; this can exacerbate the headaches and increase frequency (Blanda).

Source: Medical Disability Advisor



Factors Influencing Duration

Length of disability depends on the severity, frequency, and duration of migraine headaches, along with the individual's response to treatment.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Often the migraine sufferer may be unable to work or perform job responsibilities during a migraine headache episode. Heavy physical activity may also be limited. Providing a dark, quiet room where the individual can rest until the attack passes may be helpful.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has diagnosis of migraine been confirmed? Is it classified as with or without aura?
  • Have other conditions with similar symptoms been ruled out?
  • Has individual experienced complications related to migraine headaches, such as mixed headache syndrome, rebound headaches from excessive use of painkillers, chronic daily headaches, or thrombotic stroke?
  • Does individual have a coexisting condition that may limit treatment options or affect recovery?

Regarding treatment:

  • Does individual require medical intervention for most episodes of migraine headaches?
  • Is a change in medication or combination therapy warranted?
  • Would individual benefit from self-administered medication?
  • Have headache triggers (certain foods, alcohol, insufficient sleep, stress, hormonal changes associated with the menstrual cycle) been identified and eliminated, if possible?
  • Is individual on prevention therapy?
  • Would a combination-drug prevention therapy be more effective?

Regarding prognosis:

  • Is individual compliant with prescribed treatment plan?
  • Does individual self-administer medication during the aura phase whenever possible?
  • Has individual modified lifestyle factors that may trigger migraine episodes?
  • Does individual communicate changes in headache frequency or severity to the doctor so that treatment adjustments can be made?

Source: Medical Disability Advisor



References

Cited

Blanda, Michelle, and Jeff Wright. "Headache, Migraine." eMedicine. Eds. Edward A. Michelson, et al. 3 Sep. 2008. Medscape. 6 Jul. 2009 <http://emedicine.medscape.com/article/792267-overview>.

Sahai-Srivastava, Soma, and David Y. Ko. "Pathophysiology and Treatment of Migraine and Related Headache." eMedicine. Eds. Joseph R. Carcione, et al. 4 Sep. 2008. Medscape. 6 Jul. 2009 <http://emedicine.medscape.com/article/1144656-overview>.

Source: Medical Disability Advisor