As a Primary Care Physician (PCP), would you consider granting short-term disability for patients with recurring migraines?

Short-Term Disability for Recurring Migraines

Yes, as a PCP, you should consider granting short-term disability for patients with recurring migraines when they meet criteria for chronic migraine (≥15 headache days/month for ≥3 months with ≥8 days meeting migraine criteria) or demonstrate severe work-related disability, as these patients experience documented inability to work and perform routine activities.

Understanding the Disability Burden

Chronic migraine causes substantial work disability that justifies short-term disability consideration. The evidence clearly demonstrates that:

• Patients with chronic migraine experience severe disability including inability to work, attend social functions, and perform routine chores 1
• 12.3% of chronic migraine patients report employment disability (short- or long-term disability status), compared to only 4.4% of those with low-frequency episodic migraine 2
• Headache frequency directly correlates with increased likelihood of self-reported employment disability 2
• Chronic migraine patients have markedly more severe disability than those with episodic migraine (<15 headaches/month) 1

Clinical Assessment Framework

Step 1: Confirm Diagnosis and Severity

Document headache frequency using specific criteria:

• Ask: "Do you feel like you have a headache of some type on 15 or more days per month?" 1
• Chronic migraine requires ≥15 headache days/month for ≥3 months, with ≥8 days meeting migraine criteria 1
• Have patients maintain a headache diary, as they often underreport milder headache days 1

Step 2: Quantify Work-Related Disability

Use validated disability assessment tools:

• Administer the MIDAS (Migraine Disability Assessment) questionnaire to objectively measure migraine-related disability 2
• Assess specific work difficulties: inability to complete tasks, missed workdays, reduced productivity 3
• Patients with higher work difficulty scores display significantly higher disability levels across all functional domains 3

Step 3: Evaluate Treatment Status

Consider disability in the context of treatment optimization:

• Determine if the patient has failed appropriate prophylactic and acute treatments 1
• Assess for modifiable exacerbating factors and comorbidities 1
• Consider whether specialist referral has occurred or is needed 1

When to Grant Short-Term Disability

Approve short-term disability when:

• Patient meets chronic migraine criteria (≥15 headache days/month) with documented work impairment 1, 2
• MIDAS score indicates severe disability despite treatment attempts 2
• Patient demonstrates inability to perform essential job functions during acute exacerbations 1
• Short-term leave is needed to optimize treatment regimen or await specialist evaluation 1

The duration should be:

• Typically 4-12 weeks to allow for treatment optimization and specialist consultation 1
• Renewable based on response to prophylactic therapy and functional improvement 1

Critical Pitfalls to Avoid

Do not deny disability solely because:

• The patient has "only" episodic migraine—even moderate-frequency episodic migraine (5-9 days/month) shows increased employment disability rates 2
• There is discordance between MIDAS scores and self-reported employment disability, as both measures capture different aspects of impairment 2
• The patient appears well during the office visit, as migraine is an episodic disorder with severe disability during attacks 1

Ensure proper documentation includes:

• Specific headache frequency and duration over the past 3 months 1
• MIDAS or similar validated disability assessment scores 2
• Failed treatment attempts and current management plan 1
• Functional limitations specific to the patient's occupation 3

The Economic and Quality of Life Justification

Chronic migraine is associated with substantial economic burden and dramatically reduced health-related quality of life compared to episodic migraine 1. Providing short-term disability allows patients to:

• Focus on treatment optimization without the stress of work performance 1
• Attend necessary specialist appointments 1
• Break the cycle of medication overuse that often accompanies chronic migraine 3
• Potentially prevent progression from episodic to chronic migraine through intensive treatment 4

The goal of short-term disability is not permanent work cessation but rather a therapeutic window to achieve better migraine control and restore function 1, 2.