Most people have had a severe headache at some point in their lives. Severe enough to want to leave work early, down a handful of over-the-counter pain relievers, and curl up in bed. But what if that headache happened almost every day? And what if it came with lightning bolts through your vision and overwhelming nausea and vomiting? How would you find a way to care for your family or go to work? What would you do if you couldn’t? These are some of the questions that individuals with chronic migraine face on a daily basis.

Although the term “migraine” is frequently used in everyday language to describe a severe headache, most severe headaches are not true migraines. A number of specific features distinguish true migraine headaches from other types of headache, regardless of the severity of headache pain.

Most individuals with chronic migraines develop headaches in adolescence or early adulthood. Classically, the headache is described as one-sided and throbbing in nature, gradually worsening, and lasting anywhere from four hours to three days. The headache is commonly associated with nausea and vomiting, aversion to light (photophobia), and aversion to sound (phonophobia). Migraines also typically worsen with daily activities, even if the activity does not involve strenuous exertion. Absence of these features makes a headache unlikely to be a true migraine.

Many migraines are also associated with vision changes called auras – flashes of light or other visual aberrations that can obscure part of an individual’s sight. Less commonly, people can also have stroke-like symptoms such as partial vision loss, difficulty speaking, numbness and tingling, incoordination, and/or weakness. Most of the time these issues resolve by the end of the headache event, but their presence can dramatically affect an individual’s ability to continue to function during a headache attack.

Like other types of headaches, migraines can be triggered by emotional or physical stress. But unlike other headaches, many migraine triggers are more discrete – lack of sleep, missed meals, certain odors, specific foods (commonly chocolate and cheese), alcoholic beverages (classically red wine), menstrual cycles, bright lights/loud noises, and certain medications.

Clinically, migraines are divided into two general categories – common and classic – based on the absence or presence of auras respectively. Each type of migraine can then be classified as chronic (meaning headaches more than 15 days per month) or intermittent (headaches less than 15 days per month). Chronic migraine is associated with decreased health-related quality of life as well as higher rates of disability and increased direct and indirect costs.

The Scope of the Issue – Understanding the Impact of Migraines in the Workplace

Migraine headaches are prevalent – affecting 15-18% of the population. There are over a billion people worldwide who have migraines with approximately 40 million in the US. With typical onset in the late teens and increased improvement in the elderly, migraine is a condition predominantly affecting individuals at the peak of their professional productivity. In a study from Cephalgia, 76% of individuals with migraine reported that their condition had a negative impact upon their attendance at work. This raises important implications for employers worldwide.

Because women are affected by migraines three to four times more often than men, professions that tend to employ predominantly women, such as teaching and nursing, are disproportionately affected by this condition. Therefore, public education institutions and hospitals can be more significantly impacted than some private sector industries that tend to have a more gender-balanced workforce.

According the Harvard Business Review, an average of 4.4 workdays per year are lost due to migraines. Even more telling, there are an additional 11.4 days per year spent with reduced productivity. The overall financial impact to US employers is estimated at upwards of $2800 per employee and over $13 billion dollars a year overall, with the vast majority of these costs coming from reduced productivity as opposed to sick days.

Workplace environmental factors can play a role in the frequency and severity of migraine attacks. Certain jobsite features can expose affected employees to known headache triggers. Common triggers often include exposure to odors from cleaning supplies or air fresheners, exposure to bright/flickering lights, noise exposure, and prolonged computer use. Frequent travel requirements, shift work, and irregular break/meal times also exacerbate migraines. And a high-stress work environment (due to actual duties or perceived experiences) will typically contribute to an increase in migraine frequency as well.

According to the 2019 Global Disease Burden study, migraine is the leading cause of disability among women ages 15-49 worldwide. It is also the second leading cause of disability overall in both men and women of all ages (low back pain is the first) on level four analysis of discrete conditions. Major depression and age-related hearing loss rounded out the top three respectively. Despite these statistics, relatively little attention is given to migraine headaches in the media or in the workplace. According to a recent survey, only one in five workers believe that migraines are a serious enough health problem to warrant taking time off work. Yet this perception is discordant with a study which reported that twenty percent of people with chronic migraines consider themselves “occupationally disabled.”

Individuals with intermittent migraines are often adequately covered by FMLA benefits. Medical conditions with occasional short periods of incapacity breaking up otherwise symptom-free stretches of time are often best managed through programs such as intermittent FMLA. This allows individuals job protection during an acute migraine attack when they are unable to work for one or two days.

Individuals with chronic migraines, however, typically have a headache frequency (at least 15 headache days per month) which exceeds reasonable FMLA coverage. Although migraine is not always considered a disability under the ADA, individuals with chronic migraine usually can request ADA accommodations, which may or may not be successful in reducing headache frequency to manageable levels.

Many potential ADA accommodations for migraine are relatively inexpensive and easy to implement. Things like blue light screen filters, ergonomic workstations, noise-cancelling headphones and dedicated quite areas can often lead to dramatic improvement in productivity rates. Requesting all employees to refrain from wearing strong perfumes and eating food in work areas are also relatively easy interventions that can make a difference.

Beyond individual ADA accommodations, individuals with migraine are also demonstrated to benefit disproportionately more from interventions that help all employees such as easy access to gyms, increased natural lighting, improved access to water/restroom breaks, the ability to work from home intermittently, and measures to decrease workplace stress.

Despite attempted accommodations, individuals with chronic migraines that have been refractory to medical treatment often need to file for long-term disability once their short-term benefits have been exhausted. Historically, the Social Security Administration (SSA) has been reluctant to approve benefits for conditions like migraine which do not have measurable physical signs. Approval rates for claims for migraines are less than half the approval rates for other conditions. In 2019 the SSA issued a non-binding ruling which indicated that although primary headache disorder was not a listed impairment, the condition, alone or in combination with other disorders, could now be medically considered.

Despite these changes, workplace stigma surrounding migraines remains common. Even as numerous new preventive and acute treatment options are being developed, more and more individuals are pursuing disability benefits for chronic migraines which have been refractory to multiple medical treatments.

Part of the reason migraines are so difficult to treat successfully is that there are multiple different pathways in the brain that are affected to cause a migraine. One medication often cannot get at all of them very well. Additionally, because these medications treat the brain, they have to cross into the brain where they can have additional, less desirable, effects.

Most migraine prevention medications cause fatigue and drowsiness, which can be problematic if your occupation involves operating heavy machinery or driving a school bus. They also can lead to sleep problems and nightmares, weight gain or loss, issues with coordination, diarrhea, and dizziness. Side effects of traditional migraine medications are common and can be severe enough to require a medication change.

New migraine prevention medications are actually lab-created antibodies against some of the chemicals produced by the brain during a migraine. They have to be given by injection or intravenous infusion and, although dramatically effective for some, they can be cost-prohibitive for many individuals. Even these innovative new treatments only reduce headache frequency by 3-6 days per month on average. This means that someone may still have more than 10 days a month with headache, a frequency typically high enough to preclude full-time employment.

The challenges of treating an acute migraine attack are equally substantial. Although there are now new options added to the traditional “triptans” and ergotamines, the biggest challenge for all of these medications is the same – rebound headache. If any type of acute treatment is used too frequently, then on days the medication is not used, the body develops a withdrawal-like syndrome and a rebound headache occurs. For individuals with chronic migraine and a high headache frequency, this means deciding on a daily basis whether their symptoms are severe enough, whether the obligations of the day are important enough, to take a precious dose of medication.

Migraine is an “invisible illness” meaning that if you pass an individual with migraines on the street, there is often no visible indication they have any kind of physical or mental impairment. And for those with only intermittent headache attacks, odds are high that when you walk past them, they may not have any active impairment. But for individuals with chronic migraine and severe headaches more than 50% of their daily lives, the physical and mental toll of the condition can be staggering. The challenge lies in identifying, quantifying, and documenting these effects to support a disability benefit application.

Disability has been and will likely remain a field based upon objective medical evidence. This places individuals with migraines and other primarily subjective conditions at an initial disadvantage during disability evaluation. These challenges are present in clinical medicine as well, and physician researchers have been working to develop clinical tools to turn the constellation of subjective information into objective data. This data can then be tracked over time to yield a more concrete picture of an individual’s disease course.

The classic headache diary is now augmented by clinical tools such as the Migraine Disability Assessment (MIDAS) questionnaire and the Headache Impact Test (HIT), which are two brief scoring measures validated to accurately reflect the severity of an individual’s migraines. These tools are now used by neurologists to track the status of an individual’s migraines longitudinally through the course of treatment. Scoring systems such as these allow providers to objectively quantify the effectiveness of attempted preventive and acute treatment interventions.

The depth and breadth of available migraine treatments has significantly increased over the last ten years. Once upon a time options were limited to a handful of medications for prevention and treatment of acute attacks, with Botox being reserved only for those with prolonged refractory symptoms. Today there are multiple new oral and injectable medications for both prevention of migraine attacks and treatment of an acute headache and Botox has become more widely accessible.

These new treatment options bring hope to individuals with refractory chronic migraine, but they also create challenges for disability evaluation. Migraine is already widely perceived as a “treatable” condition, yet the Global Disease Burden study statistics clearly demonstrate that a significant percentage of individuals with the condition have not responded, or do not have access to, adequate treatment. Further, expanding the arsenal of available interventions has the potential to make the establishment of permanence more difficult.

The importance of solid clinical documentation by the attending provider of attempted treatments, adequacy of the trial of therapy, and outcomes of treatment cannot be understated. Documentation of medical assessment, especially neurological assessment, during a migraine attack is also essential – especially for individuals who suffer from associated transient visual or other neurological impairments. These forms of hard data can be taken in conjunction with the more subjective information in the medical file to paint a clearer picture of an individual’s overall degree of impairment from his or her migraines.

The nuances of disability evaluation in individuals with migraine illustrate the importance of having specially trained medical professionals evaluate applications for disability benefits. By utilizing a Disability Management firm accredited as an IRO, a disability carrier, disability retirement program, or benefit administration company can ensure that their members are receiving an unbiased and comprehensive evaluation of their medical status.

Working with an IRO allows the members to have their claims evaluated by a licensed physician who has been credentialed to ensure that they have the necessary expertise to perform a quality assessment. The physician selected will have experience treating the member’s condition(s) and an in-depth knowledge of the nuances of the condition as well as the disability field in general. In the case of an individual with migraine, the understanding of the interplay between the objective data, subjective reporting, and workplace constraints is key to evaluating whether incapacity exists.

An independent physician reviewer uniquely trained in disability also has the necessary objectivity to evaluate the medical data free of bias from any longitudinal treatment relationship with the individual or any financial relationship with the member’s benefit program. The final reports are comprehensive and reassure both the members and the benefit program that the claims have been thoroughly evaluated.

MMRO is an innovative Disability Management firm, who is a URAC-accredited Independent Review Organization with an extensive network of board-certified Disability Physician Reviewers. Our expert panel is comprised of over 325 Clinical Reviewers representing all major medical specialties and sub-specialties, all of whom have met our stringent credentialing standards. Through careful selection of experts, continuous process improvement, and customization for our clients’ individual needs, MMRO takes steps to ensure the clinical integrity and accuracy of every disability review.

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