- D R A F T -
Title 38 relevant Migraine related
VASRD section taken from July 1999:
MAGNUM, The National Migraine
Association's Recommendation For Upgrading Title 38: Chapter I: Part
4: Section 4.124a: Sub-section 8100 Migraine's Rating to Reflect the
Current Medical Understanding of Migraine Disease
Prepared for United
States Senators Charles S. Robb, John W. Warner, and John McCain and
other members of the Senate Arms Committee February 18th, 2000
By
Michael John Coleman, Executive Director & Founder
Terri Miller Burchfield, Legislative Director & Executive Vice President
Of
M.A.G.N.U.M., The National Migraine Association
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Current
Rating
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8100 Migraine:
With very frequent completely prostrating and prolonged attacks productive
of severe
economic inadaptability....................................................................................................50
With characteristic prostrating attacks occurring on an average once
a month over last
several months..................................................................................................................30
With characteristic prostrating attacks averaging one in 2 months over
last several
months..............................................................................................................................10
With less frequent attacks..................................................................................................0
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Recommended
New Revised Rating
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8100 Migraine:
With very frequent severe and completely prostrating
and prolonged intractable
attacks productive of severe economic inadaptability......................................................100
With characteristic severe and prostrating attacks
occurring on an average two to three times a month over last several
months, or 8 to10 moderate attacks a month over last
several months..................................................................................................................60
With characteristic moderate to severe and prostrating
attacks averaging one a month over last several months, or at least
2 moderate attacks per months over last several
months..............................................................................................................................30
A confirmed diagnosis of Migraine with a history
of prostrating attacks..........................10
A confirmed diagnosis of Migraine with history
of severe attacks......................................0
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Explanation of Fact Regarding Migraine as a Neurological
Disease and it's Relationship to Epilepsy
After careful consideration,
and based upon the understanding that the Schedule for Rating Disabilities
is to be revised upon better understanding of medical conditions contained
within it's body, we present the following position to support the above-mentioned
new rating structure for Title 38: Chapter I: Part 4: Section 4.124a:
Sub-Section 8100 Migraine. According to the Department of Veterans Affairs,
Title 38 was placed into law in 1945. To that fact, Sub-section 8100
has never been upgraded and is therefore based upon medical knowledge
that is over 50 years old.
Migraine as a Neurological Disease
In 1945, Migraine was not
understood to be a neurological disease, but rather considered a personality
disorder or a somatoform. According to the most widely used and accepted
current medical findings, Migraines are not somatoform, are not psychogenic,
and are not psychological. Migraine is, instead, an organic neurological
disease. The New England Journal of Medicine1
reported specifically that "Studies of regional cerebral blood flow
have helped clarify the biological basis of Migraine." The article
goes on to say that "It is time for many practitioners of medicine to
change their views and to acknowledge that Migraine is a neurobiologic,
not a psychogenic, disorder."
To further illustrate this
fact, a separate peer reviewed paper published in the same prestigious
medical journal featured a case study (there have been innumerable new
case studies since that further solidify this point) that used positive-emission
tomography to document the neurobiologic basis of Migraine disease.
In this Journal article, Woods et al 2
confirmed previous studies of Migraine disease that identified regional
cerebral blood flow and highlighted important new clinical observations.
This study documented, as Olsen points out, "...beyond any reasonable
doubt that spreading hypoperfusion is a real phenomenon. Most observations
of regional cerebral blood flow in Migraine without aura have been normal,
unlike those in Migraine with aura 3,4."
Migraine is a disease of
equal severity to and productive of equivalent economic inadaptability
as other impairments on the Veterans Affairs Schedule for Ratings Disability
(VASRD), such as Sub-section 8910 Epilepsy, grand mal (rate under the
general rating formula for major seizures), and 8911 Epilepsy, petit
mal (a thorough study of all material in Secs. 4.121 and 4.122 of the
preface and under the ratings for epilepsy are listed as necessary prior
to any rating action.) Hence the medically equivalent impairment is
listed: Epilepsy. We suggest considering the fact that both Migraine
and Epilepsy are convulsive disorders, and note that convulsive disorders,
regardless of etiology and degree of impairment, the impairment should
be determined according to type, frequency, duration, and sequelae of
seizure (i.e. attacks). Based upon the close relationship between the
two diseases, the Schedule for Rating Disabilities should use similar
scale to rate the level of impairment. In addition, MAGNUM took under
consideration comments regarding this suggested revision made by Dr.
Carol McBrine, of the Department of Veteran Affairs, Office of Compensation
& Pension Services.
The Relationship Between Migraine and Epilepsy
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 5. 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.
Seizures and Migraines 6
Migraine and seizures. The frequency of Migraine in an Epileptic
population has been variably reported as 8.4% to 23% and the reported
frequency of epilepsy in a Migraine population ranges from 1% to 17%.
MELAS, arteriovenous, head trauma, and systemic lupus erythematosis
can result in seizures and Migraines or Migraine like headaches. Migraine
with typical or prolonged aura, basilar Migraine, and catamenial Epilepsy
can be triggers for seizures. Migraine can cause a cerebral infarction
which can cause seizures 7.
Benign occipital Epilepsy,
benign rolandic Epilepsy, and temporal and occipital lobe Epilepsy can
cause seizures which mimic some features of Migraine. A seizure is more
likely if the aura is less than 5 minutes and associated with alteration
of consciousness, automatisms, and abnormal motor activity such as tonic-clonic
movements. Migraine is more likely if the aura lasts more than 5 minutes
and has positive (tingling, scintillations) and negative features (visual
loss, numbness).
Ictal and postictal headaches. Hemicrania epileptica or synchronous
ipsilateral ictal headache with Migraine features is a cause of headaches
caused by a seizure. Most patients have both ictal headaches and some
other seizure manifestations although ictal headaches can be the only
symptom. The seizure discharges, usually on the same side as the ipsilateral
headache, begin and end simultaneously with the headache. The headaches
usually last a few seconds to minutes. Unilateral or bilateral headaches
can occur during a temporal lobe seizure 8.
Postictal headaches are common
after partial complex and generalized tonic-clonic seizures, reported
by 51% of subjects in one study 9.
The headaches can be Migraine or tension like.
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 recently 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.
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.
VASDR Sub-Section 8100 Migraine Revised
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, specifically Intractable Migraine, can be determined
to be medically equivalent to Epilepsy under the existing evaluation
criteria. Even though a 100% or total disability rating would be possible
in severe enough Migraine cases under the Total Disability Rating and
Analogous Rating principles, the existence of established percentage
ratings with a 50% disability maximum under Code 8100 discourages such
findings in appropriate cases. The percentages and criteria for arriving
at the same ought to be modified as suggested. Such revision would bring
the VASRD current and allow for fair treatment of our servicemen and
servicewoman suffering from Migraine disease.
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