Case Name in Social Security Case - Unavailable

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF NORTH CAROLINA
STATESVILLE DIVISION
CASE NO. 5:25-CV-108-KDB-DCK
THIS MATTER IS BEFORE THE COURT on “Plaintiff’s Social Security Brief”
(Document No. 6) and “Defendant’s Brief” (Document No. 7). This case has been referred to the
undersigned Magistrate Judge pursuant to 28 U.S.C. §636(b). After careful consideration of the
written arguments, the administrative record, and applicable authority, the undersigned will
respectfully recommend that the Commissioner’s decision be affirmed.
BACKGROUND
Plaintiff Stephanie McInnes (“Plaintiff”), through counsel, seeks judicial review of an
unfavorable administrative decision on an application for disability benefits. (Document No. 1).
Plaintiff filed applications for a period of disability and disability insurance benefits (“DIB”) on
or about May 26, 2022, under Title II of the Social Security Act, and for supplemental security
income (“SSI”) under Title XVI of the Social Security Act, both alleging an inability to work due
to a disabling condition beginning on or about December 23, 2018. (Transcript of the Record of
Proceedings (“Tr.”) 17). Plaintiff later amended the disability onset date to “July 16, 2020,
consistent with the car accident that worsened Claimant’s migraines.” (Tr. 40, 300); see also
(Document No. 6, p. 1).
STEPHANIE MCINNES, )
)
Plaintiff, )
)
MEMORANDUM AND
RECOMMENDATION
v. )
)
COMMISSIONER OF SOCIAL SECURITY, )
)
Defendant. )
)
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The Commissioner of Social Security (the “Commissioner” or “Defendant”) denied
Plaintiff’s applications initially on February 15, 2023, and again after reconsideration on
December 21, 2023. (Tr. 17, 107, 115, 119). In its “Notice of Reconsideration,” the Social
Security Administration (“SSA”) included the following explanation of its decision:
You said you were unable to work as of 12/23/2018 because of
migraines, neck pain, carpal tunnel, insomnia, migraines, difficulty
sleeping, and depression.
Your condition results in some limitations in your ability to perform
work related activities. We have determined that your condition is
not severe enough to keep you from working. We considered the
medical and other information, your age, education, and work
experience in determining how your condition affects your ability to
work. We do not have sufficient vocational information to
determine whether you can perform any of your past relevant work.
However, based on the evidence in file, we have determined that
you can adjust to other work.
(Tr. 121).
Plaintiff filed a timely written request for a hearing on January 29, 2024. (Tr. 17, 122-
123). On June 13, 2024, Plaintiff appeared and testified at a hearing before Administrative Law
Judge Valorie Stefanelli (the “ALJ”). (Tr. 17, 33-54). In addition, Amy Vuyovich, a vocational
expert (“VE”), and Aaron Dalton, Plaintiff’s attorney, appeared at the hearing. Id.
The ALJ issued an unfavorable decision on July 19, 2024, denying Plaintiff’s claim. (Tr.
17-27). On September 11, 2024, Plaintiff filed a request for review of the ALJ’s decision, which
was denied by the Appeals Council on May 16, 2025. (Tr. 1, 172). The ALJ’s decision became
the final decision of the Commissioner when the Appeals Council denied Plaintiff’s review
request. (Tr. 1).
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Plaintiff’s “Complaint” seeking a reversal of the ALJ’s determination was filed in this
Court on July 11, 2025. (Document No. 1). On August 5, 2025, the undersigned was assigned to
this case as the referral Magistrate Judge.
“Plaintiff’s Social Security Brief” (Document No. 6) was filed September 29, 2025; and
“Defendant’s Brief” (Document No. 7) was filed October 29, 2025. “Plaintiff’s Social Security
Reply Brief” (Document No. 8) was filed October 30, 2025.
This matter is ripe for disposition, and therefore, a memorandum and recommendation to
the Honorable Kenneth D. Bell is now appropriate.
STANDARD OF REVIEW
The Social Security Act, 42 U.S.C. § 405(g) and § 1383(c)(3), limits this Court’s review
of a final decision of the Commissioner to: (1) whether substantial evidence supports the
Commissioner’s decision; and (2) whether the Commissioner applied the correct legal standards.
Richardson v. Perales, 402 U.S. 389, 390 (1971); Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir.
1990).
The Fourth Circuit has made clear that it is not for a reviewing court to re-weigh the
evidence or to substitute its judgment for that of the Commissioner – so long as that decision is
supported by substantial evidence. Hays, 907 F.2d at 1456 (4th Cir. 1990); see also, Smith v.
Schweiker, 795 F.2d 343, 345 (4th Cir. 1986); Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir.
2012). “Substantial evidence has been defined as ‘more than a scintilla and [it] must do more than
create a suspicion of the existence of a fact to be established. It means such relevant evidence as
a reasonable mind might accept as adequate to support a conclusion.’” Smith v. Heckler, 782 F.2d
1176, 1179 (4th Cir. 1986) (quoting Perales, 402 U.S. at 401).
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Ultimately, it is the duty of the Commissioner, not the courts, to make findings of fact and
to resolve conflicts in the evidence. Hays, 907 F.2d at 1456; King v. Califano, 599 F.2d 597, 599
(4th Cir. 1979) (“This court does not find facts or try the case de novo when reviewing disability
determinations.”); Seacrist v. Weinberger, 538 F.2d 1054, 1056-57 (4th Cir. 1976) (“We note that
it is the responsibility of the [Commissioner] and not the courts to reconcile inconsistences in the
medical evidence, and that it is the claimant who bears the risk of nonpersuasion.”). “[A]
reviewing court must uphold the determination when an ALJ has applied correct legal standards
and the ALJ’s factual findings are supported by substantial evidence.” Peace v. Berryhill, 2019
WL 2406626, at *1 (4th Cir. June 7, 2019) (quoting Brown v. Comm’r Soc. Sec. Admin., 873 F.3d
251, 267 (4th Cir. 2017)). Indeed, so long as the Commissioner’s decision is supported by
substantial evidence, it must be affirmed even if the reviewing court disagrees with the final
outcome. Lester v. Schweiker, 683 F.2d 838, 841 (4th Cir. 1982).
DISCUSSION
The question before the ALJ was whether Plaintiff was under a “disability” as that term of
art is defined for Social Security purposes, between July 16, 2020, and the date last insured, March
31, 2024.1 (Tr. 17-18, 27). To establish entitlement to benefits, Plaintiff has the burden of proving
disability within the meaning of the Social Security Act. Bowen v. Yuckert, 482 U.S. 137, 146
n.5 (1987).
The Social Security Administration has established a five-step sequential evaluation
process for determining if a person is disabled. 20 C.F.R. § 404.1520(a). The five steps are:
1 Under the Social Security Act, 42 U.S.C. § 301, the term “disability” is defined as an: inability to engage
in any substantial gainful activity by reason of any medically determinable physical or mental impairment
which can be expected to result in death or which has lasted or can be expected to last for a continuous
period of not less than 12 months. Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995) (quoting 42 U.S.C.
§ 423(d)(1)(A)).
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(1) whether claimant is engaged in substantial gainful activity -
if yes, not disabled;
(2) whether claimant has a severe medically determinable
physical or mental impairment, or combination of
impairments that meet the duration requirement in §
404.1509 - if no, not disabled;
(3) whether claimant has an impairment or combination of
impairments that meets or medically equals one of the
listings in appendix 1, and meets the duration requirement -
if yes, disabled;
(4) whether claimant has the residual functional capacity
(“RFC”) to perform her/his past relevant work - if yes, not
disabled; and
(5) whether considering claimant’s RFC, age, education, and
work experience he/she can make an adjustment to other
work - if yes, not disabled.
20 C.F.R. § 404.1520(a)(4)(i-v).
The burden of production and proof rests with the claimant during the first four steps; if
claimant is able to carry this burden, then the burden shifts to the Commissioner at the fifth step to
show that work the claimant could perform is available in the national economy. Pass, 65 F.3d at
1203. In this case, the ALJ determined at the fifth step that Plaintiff was not disabled. (Tr. 24).
First, the ALJ determined that Plaintiff had not engaged in any substantial gainful activity
since July 16, 2020, the alleged disability onset date. (Tr. 19). At the second step, the ALJ found
that Plaintiff’s “migraines/headache disorder” was a severe impairment.2 (Tr. 20). At the third
step, the ALJ determined that Plaintiff did not have an impairment or combination of impairments
that met or medically equaled one of the impairments listed in 20 C.F.R. 404, Subpart P, Appendix
1. (Tr. 21).
2 The determination at the second step as to whether an impairment is “severe” under the regulations is a
de minimis test, intended to weed out clearly unmeritorious claims at an early stage. See Bowen v. Yuckert,
482 U.S. 137 (1987).
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Next, the ALJ assessed Plaintiff’s RFC and found that Plaintiff retained the capacity “to
perform a full range of work at all exertional levels, but with the following nonexertional
limitations:”
never climb ladders, ropes, or scaffolds; able to work in a moderate
noise environment; no concentrated exposure to vibration, extreme
temperatures, or humidity; no concentrated exposure to respiratory
irritants such as gases, fumes, or chemicals; no concentrated
exposure to workplace hazards such as heights, or high-speed
mechanical equipment.
(Tr. 22). In making this finding, the ALJ “considered all symptoms and the extent to which these
symptoms can reasonably be accepted as consistent with the objective medical evidence and other
evidence, based on the requirements of 20 CFR 404.1529 and 416.929 and SSR 16-3p.” Id.
At the fourth step, the ALJ held that Plaintiff could not perform past relevant work as
hairdresser. (Tr. 25). At the fifth and final step, the ALJ concluded based on the testimony of the
VE and “[c]onsidering the claimant’s age, education, work experience, and residual functional
capacity” that jobs existed in significant numbers in the national economy that Plaintiff could
perform. (Tr. 26). Specifically, the VE testified that according to the factors given by the ALJ,
occupations Plaintiff could perform included a marker, a router, and a mail clerk. Id. Therefore,
the ALJ concluded that Plaintiff was not under a “disability,” as defined by the Social Security
Act, between December 23, 2018, and the date of the decision, July 19, 2024. (Tr. 27).
On appeal to this Court, Plaintiff alleges that the ALJ “erred by failing to discuss Plaintiff’s
migraine journal in the ALJ’s RFC analysis.” (Document No. 6, p. 5). The undersigned will
address this issue below.
In the only assignment of error, Plaintiff argues that “the ALJ failed to address Plaintiff’s
migraine log that details Plaintiff’s migraine frequency, duration, and symptoms from 2015 to May
10, 2024.” (Document No. 6, p. 14) (citing Tr. 288-299). Plaintiff acknowledges that the ALJ
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questioned “Plaintiff about the migraine log at the hearing,” but states that “the ALJ decision
neither discusses nor references Plaintiff’s migraine log.” Id. (citing Tr. 45-46).
Plaintiff further argues that:
The ALJ’s failure to acknowledge the migraine log in the
decision harms Plaintiff because the migraine log provides a
contemporary account of Plaintiff’s migraine frequency and
symptoms that supports Plaintiff’s testimony and function reports,
both of which the ALJ discounted as insufficiently supported by the
record. AR 23. Furthermore, because the ALJ did not acknowledge
the migraine log in the decision, it is unclear how, or whether, the
ALJ evaluated the migraine log in crafting Plaintiff’s RFC. AR 22–
23. Plaintiff’s migraine log supports Plaintiff’s position that she
would be off-task and/or absent outside of employer tolerances,
which as VE Vuyovich testified, are no more than 10% time off-task
during the workday and no more than one absence per month. AR
52.
(Document No. 6, pp. 14-15). Plaintiff contends that even if the ALJ did not believe Plaintiff’s
testimony regarding the frequency of the migraines, less frequent migraines would still preclude
work. (Document No. 6, p. 15 (citing Tr. 52).
In support of remand, Plaintiff also asserts that “ALJs should address migraine journals as
part of the ALJ’s RFC analysis.” (Document No. 6, p. 7) (citing Wallace v. Colvin, 2016 WL
749042 (S.D.W.Va. Feb. 1, 2016). Plaintiff suggests that the ALJ’s failure to discuss the migraine
log undercuts the ALJ’s responsibility to “build an accurate and logical bridge from the evidence
of record to the ALJ’s conclusions.” (Document No. 6, pp. 8-9) (citing Monroe v. Colvin, 826
F.3d 176, 189-90 (4th Cir. 2016)). However, Plaintiff also acknowledges that “there is no rigid
requirement that the ALJ specifically refer to every piece of evidence in [her] decision.”
(Document No. 6, p. 9) (quoting Thomas v. Berryhill, 916 F.3d 307, 312 (4th Cir. 2019) (quoting
Reid v. Comm’r of Soc. Sec., 769 F.3d 861, 865 (4th Cir. 2014)).
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In response, Defendant notes that “as Plaintiff admits, the ALJ specifically questioned
Plaintiff about her migraine log during the administrative hearing.” (Document No. 7, p. 1) (citing
Tr. 45-47). Defendant further notes that the “ALJ then accurately summarized in the decision the
same subjective statements of disabling migraine-related limitations that appeared in Plaintiff’s
migraine log.” Id. (citing Tr. 23). Therefore, Defendant contends that “the record plainly
establishes that the ALJ considered Plaintiff’s migraine log when evaluating her case.” Id. (citing
Tr. 23, 45-47).
Defendant also asserts that “the ALJ generously accounted for Plaintiff’s migraine-related
limitations in the residual functional capacity finding by restricting her to no climbing, a moderate
noise environment, and no concentrated exposure to vibration, extreme temperatures, humidity,
respiratory irritants, or workplace hazards.” Id. (citing Tr. 22).
In addition, Defendant notes that the ALJ made at least two references to Plaintiff’s
testimony, as well as multiple other references to the record, addressing her migraines. (Document
No. 7, p. 4) (citing Tr. 23) (citing Tr. 238, 300-301 and Testimony). Defendant also agrees with
Plaintiff that “the ALJ was not required to refer to every piece of evidence contained in the record.”
Id. (citing Thomas v. Berryhill, 916 F.3d at 312).
Defendant summarizes Plaintiff’s treatment history, as discussed by the ALJ, as follows.
Plaintiff “went to went to see her medical providers when it was
time to renew the prescriptions for her medication” (Tr. 23). In
particular, the ALJ noted that Plaintiff requested migraine
medication when she established care with a primary care provider
in December 2019 (Tr. 23, citing Ex. 1F; Tr. 309). At that time,
Plaintiff said medication worked well without side effects and she
did not recount significant migraine complaints or symptoms. Id.
Plaintiff returned to the provider in March 2021, at which time she
“did not report to them the alleged severity of her migraine
symptoms” (Tr. 23, citing 1F/2,5; Tr. 312). Rather, Plaintiff said
she was “[o]verall feeling well” and she “requested a refill of her
migraine medication and an additional prescription for ibuprofen”
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(Tr. 23, citing 1F/5; Tr. 312-13). In July 2022, Plaintiff “reported
that she did not take her migraine medication immediately upon
onset of a migraine and was instructed not to delay taking her
medication” (Tr. 23, citing 3F/1-2; Tr. 361-62). In March 2023, her
last visit with a medical provider for migraines, Plaintiff “reported
her migraines occurred intermittently, were aggravated by stress,
that she had been taking medications and that the treatment provided
significant relief” (Tr. 23, citing 4F/4; Tr. 368, 370). As the ALJ
further observed, although Plaintiff “described her migraines as
‘debilitating’ to the consultative examiner, the claimant did not
report this to her medical providers at any time” (Tr. 23, citing Ex.
8F; Tr. 400).
(Document No. 7, p. 7) (citing Tr. 23).
In forming the RFC, the ALJ actually “assessed greater restrictions” than the consultative
examiner and state agency experts, “noting that the evidence of record, including claimant’s
testimony, supports the addition of temperature limitations to the residual functional capacity”).
(Document No. 7, pp. 7-8) (citing Tr. 24-25). Defendant further notes that Plaintiff has not offered
any “contrary medical opinion suggesting that her migraines caused any work-related limitations
(let alone work-preclusive ones).” (Document No. 7, p. 8).
Defendant also observes that the ALJ discussed Plaintiff’s activities as follows:
she reported that she was “able to complete most tasks associated
with activities of daily living such as driving, preparing meals,
watching TV, reading, and managing funds” (Tr. 21, citing Ex. 6E;
Tr. 221-28, 239-53, 393, 401). She cared for her personal needs, her
pets, and her elderly mother; shopped in stores; managed her
finances; and enjoyed exercising, hiking, yoga, biking, and crafting.
Id.
Id. (citing Tr. 21).
In conclusion, Defendant contends that the ALJ decision “built an accurate and logical
bridge from the record to her fact-finding about Plaintiff’s migraine-related limitations” and that
the evidence the ALJ relied on “easily surpassed the substantial evidence threshold.” (Document
No. 7, pp. 8-9).
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In reply, Plaintiff suggests that discussing the migraine log during the hearing and
referencing Plaintiff’s testimony related to her migraines in the ALJ decision is insufficient.
(Document No. 8, p. 2). Plaintiff contends that “[h]ad the ALJ evaluated Plaintiff’s migraine log
in the written decision, it is reasonable to expect the outcome of the decision would be different
because the migraine journal supports Plaintiff’s testimony and the decision as written provides
no insight into how, or whether, the ALJ evaluated the journal.” Id. (Emphasis added). Plaintiff
concludes that remand is required because there is an “entire class of evidence that the ALJ failed
to discuss, namely, Plaintiff’s migraine journal that dates back to 2015.” (Document No. 8, p. 4);
see also (Tr. 288-299).
The undersigned finds Defendant’s arguments most persuasive.
The ALJ decision here was entirely focused on Plaintiff’s only severe impairment,
migraines/headache disorder. (Tr. 17-27). The ALJ opined that Plaintiff’s “medically
determinable impairments could reasonably be expected to cause the alleged symptoms; however,
the claimant’s statements concerning the intensity, persistence and limiting effects of these
symptoms are not entirely consistent with the medical evidence and other evidence in the record
for the reasons explained in this decision.” (Tr. 23).
In the process of finding that Plaintiff was not under a disability during the relevant time
period, the ALJ’s decision was supported by substantial evidence from the record, and the ALJ
applied that evidence in determining Plaintiff’s RFC. The undersigned notes the following
pertinent section of the decision.
The evidence of record establishes that the claimant went to see
her medical providers when it was time to renew the prescriptions
for her medication. In one visit, the claimant reported that she did
not take her migraine medication immediately upon onset of a
migraine and was instructed not to delay taking her medication
(3F/1-2). The last visit with a medical provider was in March 2023
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where the claimant reported her migraines occurred intermittently,
were aggravated by stress, that she had been taking medications and
that the treatment provided significant relief (4F/4). The record
reflects that while the claimant described her migraines as
“debilitating” to the consultative examiner, the claimant did not
report this to her medical providers at any time (8F).
In formulating the residual functional capacity above the
undersigned has considered the medical evidence of record as well
as the claimant’s subjective complaints. By limiting the
claimant’s exposure to noise and respiratory irritants, as well as
extreme temperatures and humidity, the undersigned has
accounted for conditions that may trigger a migraine. By placing
a prohibition on the claimant climbing ladders, ropes, and scaffolds,
as well as workplace hazards the undersigned has accounted for
the claimant’s safety in the onset of a migraine as well as
medication that may reduce reaction time or cause drowsiness.
(Tr. 23-24)(emphasis added).
The parties agree that the ALJ discussed Plaintiff’s migraine log at the hearing. (Tr. 45-
46). In that discussion, Plaintiff acknowledged that she did not tell her doctor that she was keeping
a log, and never showed the log to him. (Tr. 46).
The parties also agree that that “there is no rigid requirement that the ALJ specifically refer
to every piece of evidence in [her] decision.” See (Document No. 6, p. 9) and (Document No. 7,
p. 4) (quoting Thomas v. Berryhill, 916 F.3d 307, 312 (4th Cir. 2019).
The undersigned is very sympathetic to the pain and complications that might be caused
by Plaintiff’s migraine headaches; however, the undersigned finds the ALJ has reached a decision
supported by substantial evidence that is unlikely to have been changed by specifically citing to
Plaintiff’s migraine log.
CONCLUSION
The undersigned finds that there is “such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion,” and thus substantial evidence supports the
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Commissioner’s decision. Richardson v. Perales, 402 U.S. 389, 401 (1971); Johnson v. Barnhart,
434 F.3d 650, 653 (4th Cir. 2005). As such, the undersigned will recommend that the
Commissioner’s decision be affirmed.
RECOMMENDATION
FOR THE FOREGOING REASONS, the undersigned respectfully recommends that:
the Commissioner’s determination be AFFIRMED.
TIME FOR OBJECTIONS
The parties are hereby advised that pursuant to 28 U.S.C. § 636(b)(1)(C), and Rule 72 of
the Federal Rules of Civil Procedure, written objections to the proposed findings of fact,
conclusions of law, and recommendation contained herein may be filed within fourteen (14) days
of service of same. Responses to objections may be filed within fourteen (14) days after service
of the objections. Fed.R.Civ.P. 72(b)(2). Failure to file objections to this Memorandum and
Recommendation with the District Court constitutes a waiver of the right to de novo review by the
District Court. Diamond v. Colonial Life, 416 F.3d 310, 315-16 (4th Cir. 2005); United States v.
Benton, 523 F.3d 424, 428 (4th Cir. 208). Moreover, failure to file timely objections will preclude
the parties from raising such objections on appeal. Id. “In order ‘to preserve for appeal an issue
in a magistrate judge’s report, a party must object to the finding or recommendation on that issue
with sufficient specificity so as reasonably to alert the district court of the true ground for the
objection.’” Martin v. Duffy, 858 F.3d 239, 245 (4th Cir. 2017) (quoting United States v. Midgette,
478 F.3d 616, 622 (4th Cir. 2007)).
IT IS SO RECOMMENDED.
Signed: April 20, 2026
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