ALJs Must Address SSR 19-4p and Listing 11.02(B) When Evaluating Migraines at Step Three

Case: Pakita Wright v. Commissioner of Social Security
Court: United States Court of Appeals for the Eleventh Circuit
Date: 2026-05-27
Disposition: Reversed and remanded (step-three analysis of migraines)

I. Introduction

Pakita Wright sought Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) and alleged disability including migraine headaches, which the Administrative Law Judge (“ALJ”) found to be a severe impairment at step two. The ALJ nonetheless denied benefits. Wright appealed, contending that the ALJ failed to properly evaluate her migraines at step three—specifically, by not addressing whether her migraines medically equaled epilepsy under Listing 11.02(B) as contemplated by Social Security Ruling (“SSR”) 19-4p. She also challenged the ALJ’s treatment of her subjective complaints.

The Eleventh Circuit reversed, holding that the ALJ’s decision lacked sufficient discussion to permit a reviewing court to infer that the ALJ actually performed the required SSR 19-4p/Listing 11.02(B) medical-equivalence analysis for migraines at step three.

II. Summary of the Opinion

The Eleventh Circuit emphasized that primary headache disorders are not listed impairments, but SSR 19-4p recognizes that they may medically equal the epilepsy listings—most notably Listing 11.02(B). The court found that the ALJ:

• did not cite or discuss Listing 11.02 or SSR 19-4p;
• issued only a conclusory step-three statement that no listing was met or equaled;
• did not adequately discuss the elements SSR 19-4p requires for equivalence to Listing 11.02(B), such as a medical source’s detailed description of typical headache events and treatment side effects.

Because the written decision did not demonstrate that the ALJ evaluated migraines under the SSR 19-4p framework, the court reversed and remanded for the ALJ to “properly consider Wright’s migraine headaches at step three” by addressing whether they meet or medically equal Listing 11.02(B) under SSR 19-4p.

III. Analysis

A. Precedents Cited

1) Appellate review framework: final decision, standards of review, and substantial evidence

• Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001): Used for the proposition that when the Appeals Council denies review, the ALJ’s decision is the Commissioner’s final decision for judicial review. This frames the target of the court’s review.
• Viverette v. Comm'r of Soc. Sec., 13 F.4th 1309, 1313-14 (11th Cir. 2021): Cited for de novo review of legal standards and substantial-evidence review for factual support. This is key because Wright’s argument sounded in legal error (failure to apply/reflect the correct step-three framework), not merely factual dispute.
• Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011): Defines “substantial evidence” and reiterates that reviewing courts may not reweigh evidence. The panel relied on this boundary to explain why it could not “fill in” missing analysis by independently assessing medical equivalence.

2) Record development and adequacy of articulation

• Welch v. Bowen, 854 F.2d 436, 440 (11th Cir. 1988): Recognizes the ALJ’s obligation to develop a full and fair record. While the remand here turns primarily on articulation at step three, the record-development duty underscores the ALJ’s responsibility to address the medically analogous listing identified by SSR 19-4p when migraines are severe and potentially listing-level.
• Dyer v. Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005): States there is no rigid requirement that an ALJ refer to every piece of evidence, so long as the decision is not a “broad rejection” that prevents a court from concluding the claimant was considered “as a whole.” The panel used this concept by contrast: although ALJs need not cite every item, this decision was too conclusory on the specific SSR 19-4p/Listing 11.02(B) issue to permit meaningful review.

3) Sequential evaluation process, burden at step three, and listing requirements

• Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005): Cited for the five-step sequential evaluation framework and the claimant’s burden. This anchors why the dispute is centered on step three once severe migraines were found at step two.
• Bowen v. City of New York, 476 U.S. 467, 470 (1986): Cited to note that DIB and SSI regulations are “essentially the same,” supporting the uniform application of the sequential analysis across both programs in Wright’s case.
• Barron v. Sullivan, 924 F.2d 227, 229 (11th Cir. 1991): Cited for the claimant’s burden to show that an impairment meets or equals a listing. Even though Wright bears the burden, the court held the ALJ’s decision still must show that the legally required equivalence inquiry was actually performed.
• Wilson v. Barnhart, 284 F.3d 1219, 1224 (11th Cir. 2002): Cited for what it takes to meet a listing—diagnosis plus medical documentation matching criteria and duration. The opinion then pivots to equivalence, acknowledging that migraines are not in the listings but may be evaluated by analogy.

B. Legal Reasoning

1) The controlling legal framework: SSR 19-4p and medical equivalence to Listing 11.02(B)

The court’s reasoning begins with two foundational points:

• Migraines are not a listed impairment in the Listing of Impairments.
• SSR 19-4p directs adjudicators that a “primary headache disorder” may be found medically equivalent to epilepsy under Listing 11.02(B) (or 11.02(D)), and it identifies what evidence should be considered in that equivalence analysis.

For Listing 11.02(B), the listing-level analogue is dyscognitive seizures occurring “at least once a week for at least 3 consecutive months” despite adherence to treatment. SSR 19-4p then specifies factors that should inform whether migraines are of “equal medical significance,” including:

• a medical source’s detailed description of a typical headache event (associated phenomena, aura, duration, intensity, accompanying symptoms);
• frequency of headache events;
• adherence to prescribed treatment;
• side effects of treatment (e.g., drowsiness, confusion, inattention); and
• functional limitations during the day (need for a dark, quiet room; lying down; sleep disturbance affecting daytime activities; etc.).

2) Why the ALJ’s step-three discussion was legally insufficient

The court acknowledged that an ALJ need not mechanically cite every authority or piece of evidence. But it held that the decision must contain enough information to allow a reviewing court to infer that the ALJ considered the relevant legal standard and the claimant’s condition “as a whole.”

Here, the ALJ’s step-three analysis was essentially a conclusory statement that no impairment met or equaled a listed impairment, with no discussion of Listing 11.02(B) or SSR 19-4p, even though the ALJ did “specifically set forth and analyzed other listings” for other impairments. This mattered because SSR 19-4p is the SSA’s explicit roadmap for evaluating migraines at step three—without it, the court could not determine whether the ALJ applied the correct legal standard to a severe migraine impairment.

3) The RFC discussion did not cure the step-three defect

The court noted that the ALJ mentioned migraine headaches in the Residual Functional Capacity (“RFC”) discussion, but found that this was not enough. The step-three issue is not merely whether migraines were acknowledged; it is whether the ALJ evaluated, in substance, the SSR 19-4p factors necessary to decide medical equivalence to Listing 11.02(B). The decision lacked key required components—particularly a detailed description of the migraine events and any discussion of treatment side effects—so the court could not affirm by inference.

4) Scope of remand and the subjective-symptom argument

Although Wright also argued that substantial evidence did not support the ALJ’s credibility/symptom evaluation, the panel’s disposition rests on the step-three migraine analysis defect and remands for proper consideration under Listing 11.02(B) and SSR 19-4p. The practical effect is that symptom evaluation may be revisited on remand insofar as it relates to the SSR 19-4p factors (frequency, functional interference, medication side effects), even if the appellate court did not resolve the subjective-complaint issue on the merits.

C. Impact

1) Practical rule for migraine cases in the Eleventh Circuit

The decision crystallizes an articulation requirement: when a claimant has severe migraines and raises (or the record fairly presents) the possibility of listing-level severity by analogy, an ALJ’s step-three finding should reflect an actual SSR 19-4p/Listing 11.02(B) medical-equivalence analysis. A boilerplate “no listing met or equaled” conclusion may be insufficient where the ALJ otherwise provides listing-by-listing analysis for other conditions.

2) Litigation and adjudication effects

• For claimants: The record should be developed around SSR 19-4p’s evidentiary touchpoints—documented typical headache description, frequency logs, treatment adherence, side effects, and concrete functional restrictions (e.g., time in dark room, lying down, missed activities).
• For ALJs: Decisions should explicitly connect the migraine evidence to the SSR 19-4p factors and the Listing 11.02(B) frequency/duration logic. This is especially important where migraines are found “severe” at step two, because that finding heightens the expectation of meaningful step-three analysis.
• For reviewing courts: The opinion reinforces that courts may not salvage an underexplained step-three determination by reweighing evidence or supplying missing analysis—consistent with the limits described in Winschel v. Comm'r of Soc. Sec..

3) Relationship to “substantial evidence” review

The remand is driven by legal adequacy of the analysis and explanation, not a definitive finding that Wright’s migraines equal Listing 11.02(B). This distinction matters: substantial-evidence review presupposes the ALJ applied the correct legal standard and made reviewable findings. Where the decision does not show that the correct SSR 19-4p framework was applied, substantial-evidence affirmance becomes impossible because there is no clear administrative reasoning to which deference can attach.

IV. Complex Concepts Simplified

• Step three (the “Listings” step): A shortcut to a disability finding. If an impairment meets a listed impairment (or is medically equivalent), the claimant is disabled without considering past work or other jobs.
• “Medical equivalence”: Even if a condition is not in the listings (like migraines), it can still qualify if it is as medically severe—i.e., of “equal medical significance”—as a listed condition. Here, SSR 19-4p points adjudicators to epilepsy (Listing 11.02) as the closest analogue.
• Listing 11.02(B) (epilepsy analogue): The key benchmark highlighted by the court is very frequent events (at least weekly for three months) despite treatment. SSR 19-4p translates that benchmark to migraines by requiring attention to typical event descriptions, frequency, treatment adherence, side effects, and functional disruption.
• RFC (Residual Functional Capacity): The most a person can still do in a work setting despite impairments. Mentioning migraines in the RFC section does not necessarily answer the separate step-three question of listing-level equivalence.
• Substantial evidence: A deferential standard—courts uphold the ALJ if enough relevant evidence supports the conclusion. But courts cannot reweigh evidence or supply missing reasoning; the ALJ must show the path of decision.

V. Conclusion

Pakita Wright v. Commissioner of Social Security underscores a clear administrative-law lesson in the migraine context: because SSR 19-4p expressly provides the framework for analyzing whether migraines medically equal epilepsy under Listing 11.02(B), an ALJ’s step-three decision must reflect that framework in a reviewable way. A conclusory no-listing finding—without addressing SSR 19-4p’s factors and the Listing 11.02(B) analogue—risks reversal and remand, particularly when the ALJ otherwise performs listing-specific analysis for other impairments.