Citation Nr: 1336831 Decision Date: 11/13/13 Archive Date: 11/26/13 DOCKET NO. 11-22 427 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to service connection for headaches, to include as secondary to service-connected right shoulder strain or cervicalgia. REPRESENTATION Appellant represented by: Robert Lemley WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jack S. Komperda, Associate Counsel INTRODUCTION The Veteran served on active duty from August 2002 to August 2008. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision by the Department of Veterans Affairs (VA) Hartford Regional Office (RO). In January 2012, the Veteran provided testimony before a hearing officer at the RO. A transcript of the hearing is of record. In addition to the paper claims file, the Board has reviewed the record maintained in the Virtual VA and Veterans Benefits Management System (VBMS) electronic claims files associated with the Veteran's claim. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND Additional development is required before the Veteran's claim can be adjudicated. The Veteran reports a history of headaches since he was 18 years old, prior to his entry into service. His service treatment records contain a June 2002 enlistment examination report and a report of the Veteran's medical history. The Veteran reported having taken a Tylenol for a headache five days prior to his enlistment examination, but otherwise denied a history of headaches. No pertinent defects were noted. Service treatment records show the Veteran sought treatment for a headache in May 2004. He complained of having had numbness to right side of his face for two days when looking to the right, having a migraine and losing right-sided vision. He also reported having diarrhea and feeling like his legs were about to give out. The Veteran was diagnosed with heat cramps and prescribed with additional fluids. On an April 2008 post-deployment health reassessment, the Veteran checked affirmatively that he had several health concerns, but did not indicate the same as to headaches. The health care provider specifically noted that the Veteran reported concerns as marked, but no other concerns were mentioned. Post-service, a July 2010 VA treatment record reflects the Veteran's complaints of migraine headaches since he was 18 years old, prior to active duty service. A January 2011 VA treatment record reflects the same complaints of migraine headache symptoms reported by the Veteran and the same nonfocal findings, and episodic symptoms which were infrequent and not worsening. A May 2011 VA treatment record notes the Veteran's complaints of migraine headache symptoms that worsened with the prescription of Gabapentin. The headaches occurred daily but did not change in character or location. An August 2011 VA treatment record notes that the Veteran has occasional migraine headaches. In a December 2011 VA treatment record, the Veteran was prescribed topiramate for headache prevention. During his January 2012 hearing, the Veteran maintained that he has experienced headaches accompanied with vision loss since service and headache symptoms since the age of 18. He further acknowledged he did not know whether he had a formal diagnosis of migraine headaches prior to active service. Lastly, the Veteran stated he was told by his treating VA doctor during his August 2011 and December 2011 visits that his headache symptoms may be related to his service-connected right shoulder strain. Service connection has been granted for, among other disabilities, right shoulder strain and cervicalgia. Given the Veteran's lay statements of recurrent headache symptoms accompanied by loss of vision that date back to service, his reports of symptoms of headaches that predate active service and his assertion that the headaches may be related to service-connected right shoulder or neck disabilities, a medical examination and opinion is necessary to decide this claim. 38 C.F.R. § 3.159 (c)(4) (2013). In a January 2011 statement, the Veteran acknowledged that he had been scheduled for a VA examination in connection with his claim, but had been homeless and did not receive notice of the examination. He indicated that he could now receive notice and would be willing to report for an examination. The Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655. In addition, the RO/AMC should contact the Veteran and ask him to submit any pre-service medical records that show treatment for his headache condition. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran in order to obtain the names and addresses of all medical care providers who have treated him for complaints related to his headaches prior to August 2002. The RO/AMC should then obtain and associate those records with the claims file. If the search for such records proves unsuccessful, this should be documented in the claims file. 2. After completion of the foregoing, schedule the Veteran for an appropriate VA examination to determine the current nature and likely etiology of his headache condition. The claims file must be made available to the examiner in conjunction with the examination. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. Based on the examination and review of the record, the examiner should address the following: (a) Does the evidence of record clearly and unmistakably (i.e., it is undebatable) show that the Veteran had a headache disorder that existed prior to his entry onto active duty? (b) If the answer is yes, does the evidence of record clearly and unmistakably (i.e., it is undebatable) show that the preexisting headache disorder was not aggravated by service or that any increase in disability was due to the natural progression of the disease? Please identify any such evidence with specificity. If the answer to either (a) or (b) is no, please answer the following questions: (c) Is it at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's headache disorder had its onset in service? (d) Is it at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's headache disorder is caused by his service-connected right shoulder strain or service-connected cervicalgia?. (e) Is it at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's headache disorder is aggravated by his service-connected right shoulder strain or service-connected cervicalgia?. The examiner is informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level headache disability present (i.e., a baseline) before the onset of the aggravation. A complete rationale should be provided for any opinion expressed. 3. Thereafter, readjudicate the Veteran's claim. If the decision with respect to the claim is not granted, the Veteran and his representative should be furnished a supplemental statement of the case and afforded a reasonable period of time to respond. The case should then be returned to the Board, as warranted, for appellate disposition. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).