Migraine C and P feedback-What will they rate me?

[Big Rece]

The Dr. did not add my medication. Will that hurt my chance at getting 50%? What do you think? 

LOCAL TITLE: C&P EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: MAR 31, 2016@11:30 ENTRY DATE: MAR 31, 2016@11:49:23

AUTHOR: REMBERT,FRANCIS M EXP COSIGNER: URGENCY: STATUS: COMPLETED Headaches (including Migraine Headaches) Disability Benefits Questionnaire Name of patient/Veteran:

SMITH, Maurice Is this DBQ being completed in conjunction with a VA 21-2507,

C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review ---------------

[X] VA e-folder (VBMS or Virtual VA) [X] CPRS

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: 000 Date of diagnosis: 1991

2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): developed headaches which seem to be migraine b.

Does the Veteran's treatment plan include taking medication for the diagnosed condition? [ ] Yes [X] No

3. Symptoms ----------- a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Pulsating or throbbing head pain [X] Pain localized to one side 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 c. Indicate duration of typical head pain [X] 1-2 days d

. Indicate location of typical head pain [X] Right 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

Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? [X] Yes [ ] No 5

. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No

b. 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 c. Comments, if any: No response provided.

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: says he cannot work when he has headaches 8. Remarks, if any: ------------------- No remarks provided. *********************************************************************

[Big Rece]

Thanks for the reply. I got awarded 50% for migraines. 

 

[Navy04]

Congrats on the Good News Bud. I have 50% as well, which I dont get why there is no 100%, especially since I have TBI as well. Hope you enjoy your week with the new Rating, Yah!!!

[TALON II FE]

WOW! Look at what a difference one check box can make.  I only received 30%

 1. Diagnosis    -----------

    Does the Veteran now have or has he/she ever been diagnosed with a headache    condition?    [X] Yes   [ ] No           [X] Other (specify type of headache):  Occiptial neuralga             

ICD code: R69                  Date of diagnosis: 09/17/2007                         Other diagnosis #1:  Headache syndrome              ICD code:  R69              Date of diagnosis:  08/06/2014    2. Medical History   

-----------------    a. Describe the history (including onset and course) of the Veteran's       headache conditions (brief summary):
         The veteran reports that he began experiencing occipital headaches in         (2007) when he was having an episode of vertigo.  He reports that his         symptoms worsened in (2013) and was referred to neurology where he was         initially receiving occipital nerve blocks with steroid but due to         decreased efficacy he began receiving Botox injections. The veteran         states that at his next visit he will be administered steroid and Botox.         He reports episodes of occipital headaches at least four times a year.         ***********************************************
         The veteran reports that he was diagnosed with migraine headaches;         however, this diagnosis cannot be found with the veteran's available         service treatment records. He has been diagnosed with headache syndrome         (2014); and reports that he has pain behind the right greater than left         eye. He states that while undergoing treatments for occipital neuralgia         he mentioned this headache to his Neurologist who prescribed Maxalt         which the veteran states " it helps a lot". The veteran reports that he         experiences this type of  headache at least once a week and does not         always take the Maxalt.         ******************************************************            

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):         Maxalt 10mg.            

3. Symptoms    ----------    a. Does the Veteran experience headache pain?       [X] Yes   [ ] No       [X] Constant head pain       [X] Pulsating or throbbing head pain       [X] Pain on both sides of the head       [X] Other, describe:   

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] Sensitivity to light       [X] Sensitivity to sound    c. Indicate duration of typical head pain       [X] 1-2 days    d. Indicate location of typical head pain       [X] Other, describe:             The veteran reports pain behind both eyes; right greater than left.                

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?    [X] Yes   [ ] No          If yes, provide type of test or procedure, date and results (brief      summary):        Date: 07/29/2015        Study: CT brain with and without contrast.        Impression: No acute intracranial abnormity.
    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:        The veteran reports " taking the time off when I have a headache".            8. Remarks, if any:    ------------------       None.