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Thoughts on this headache/Migraine C&P exam.

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ShuMan

Question

Team, 

I'm thinking the below C&P exam will rate me at 30%. Thoughts? feelings? Emotions?

=============================================================================

1. Diagnosis

------------

Does the Veteran now have or has he/she ever been diagnosed with a headache

condition?

[X] Yes [ ] No

[X] Migraine including migraine variants

ICD code: G43 Date of diagnosis: 2015

[X] Tension

ICD code: G44.2 Date of diagnosis: 2003

2. Medical History

------------------

a. Describe the history (including onset and course) of the Veteran's

headache conditions (brief summary):

=============================================================================

The Veteran reports he has a history of tension headaches. He reports

typically these headaches are frontal and bilateral but tend to

gravitate towards the left frontal area more often. The Veteran

reports

his headaches have changed in the last 5 years. They remain frontal

&

occur approximately 3-4 times a month, however they have increased in

severity and now require him to stop what he is doing and if he is at

work he has to leave. They now last typically 24 hours. He reports

nausea and vomits with headaches about 2 times a month.

b. Does the Veteran's treatment plan include taking medication for the

diagnosed condition?

[X] Yes [ ] No

If yes, describe treatment (list only those medications used for the

diagnosed condition):

Sumatriptan succinate 25 mgs at the onset of the headaches. He also

takes ab OTC medication that contains caffeine like Excedrin migraine

3. Symptoms

-----------

a. Does the Veteran experience headache pain?

[X] Yes [ ] No

[X] Pain on both sides of the head

b. Does the Veteran experience non-headache symptoms associated with

headaches? (including symptoms associated with an aura prior to headache

pain)

[X] Yes [ ] No

[X] Nausea

[X] Vomiting

[X] Sensitivity to light

[X] Sensitivity to sound

[X] Changes in vision (such as scotoma, flashes of light, tunnel vision)

c. Indicate duration of typical head pain

[X] Less than 1 day

d. Indicate location of typical head pain

[X] Left side of head

4. Prostrating attacks of headache pain

---------------------------------------

a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating

attacks of migraine / non-migraine headache pain?

[X] Yes [ ] No

If yes, indicate frequency, on average, of prostrating attacks over the

last several months:

[X] Once every month

b. Does the Veteran have very prostrating and prolonged attacks of

migraines/non-migraine pain productive of severe economic inadaptability?

=============================================================================

 

[ ] Yes [X] No

5. Other pertinent physical findings, complications, conditions, signs

and/or

symptoms

-----------------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs and/or symptoms related to any

conditions

listed in the Diagnosis section above?

[ ] Yes [X] No

6. Diagnostic testing

---------------------

Are there any other significant diagnostic test findings and/or results?

[ ] Yes [X] No

7. Functional impact

--------------------

Does the Veteran's headache condition impact his or her ability to

work?

[X] Yes [ ] No

If yes, describe the impact of the Veteran's headache condition,

providing

one or more examples:

As already stated, he has to call in to work approximately 3 times per

month.

8. Remarks, if any:

-------------------

STR's 29/93 headache in conjunction with other symptpoms associated

with

acute intoxication dated 01/20/2007.

CPRS note of 07/15/2015 with reference to migraines.

01/19/2006 VBMS P. 1 dated 07/02/2015 Post-deployment health assessment

STR's P. 34/93 denies headaches.

VBMS P. 1 07/02/2015 STR's P.5/93 05/26/2005 headache noted in

conjunction

with acute URI, bronchitis and sinusitis.

The Veteran has an appointment scheduled with neurology tomorrow (09/30)

for further evaluation of headaches.

No additional remarks.

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Dang, I have migraines every day....have for years since my nose was fractured on Active duty in 87. Doesn't help that I also have a herniated cervical C-6 with bone spur into nerve root.

Low grade ones I can tolerate, when they reach 7+....oh boy time for lights out, ice pack on face, in bed and load up on meds. I get those bad boys in storms of 5-7 day runs about twice a month on average.

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