Citation Nr: 0811381 Decision Date: 04/07/08 Archive Date: 04/23/08 DOCKET NO. 05-02 372 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona THE ISSUES 1. Entitlement to an increased initial evaluation for post- traumatic stress disorder with generalized anxiety disorder and major depressive disorder (PTSD) for the period between September 3, 2003 and February 17, 2005, rated as 50 percent disabling. 2. Entitlement to service connection for heart disease, including as secondary to service-connected PTSD with generalized anxiety disorder and major depressive disorder. 3. Entitlement to service connection for migraine headaches, including as secondary to service-connected PTSD with generalized anxiety disorder and major depressive disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Amy R. Grasman, Associate Counsel INTRODUCTION The veteran served on active duty from June 1968 to June 1970. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2004 RO decision denying service connection for migraine headaches and granting service connection for PTSD and assigning a 50 percent evaluation effective September 3, 2003. The Board notes that in March 2005 the RO granted a 100 percent evaluation from February 17, 2005 for PTSD. This appeal also comes before the Board from a September 2005 RO decision denying service connection for heart disease. In August 2006, the veteran testified in a Travel Board hearing in front of the undersigned Acting Veterans Law Judge regarding service connection for migraines. In June 2007, the veteran testified in a Travel Board hearing in front of one of the undersigned Veterans Law Judges regarding an increased initial evaluation for service-connected PTSD and service connection for heart disease. The transcripts of the hearings are associated with the claims file and have been reviewed. This matter is now being addressed by a panel, which includes the two Judges who conducted the Board hearings. See 38 U.S.C.A. §§ 7102(a), 7107(c) (West 2002); 38 C.F.R. § 20.707 (2007). The issue of service connection for migraine headaches is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The veteran has been notified of the evidence necessary to substantiate his claim, and all relevant evidence necessary for an equitable disposition of this appeal has been obtained. 2. Between September 3, 2003 and February 17, 2005, PTSD was manifested by intrusive thoughts, nightmares, night sweats, disturbed sleep, isolation, avoidance behavior, depression, tearfulness, shaky hands, day sweats, tension, anxiety, hypervigilance, fear of crowds, lost appetite, panic attacks, faintness, dizziness, shortness of breath, episodes of irritability, anger, blunted affect, anxious mood, fair judgment, minimal insight, impaired memory and impaired concentration; but no psychosis, impaired speech, suicidal ideation, homicidal ideation, persistent delusions or hallucinations. 3. The competent medical evidence shows that heart disease was congenital, was not incurred or aggravated in service, was not otherwise related to service, and was not caused by a service-connected disability including PTSD. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating for PTSD between September 3, 2003 and February 17, 2005 have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2007). 2. Heart disease was not incurred in or aggravated by service, nor was it proximately due to, or the result of, a service-connected disability. 38 U.S.C.A. §§ 1110, 1153 (West 2002); 38 C.F.R. §§ 3.303, 3.306, 3.310 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the claim for an increased rating for PTSD, the veteran was granted service connection for PTSD in March 2004. He filed a Notice of Disagreement (NOD) in September 2004 regarding the assigned 50 percent evaluation. The veteran was provided a VCAA letter in January 2004 regarding his service connection claim. After the NOD, a VCAA letter was sent in February 2006 regarding the veteran's claim for an increased initial rating for PTSD. These letters fully addressed all four notice elements. The letters informed the appellant of what evidence was required to substantiate the claim and of the appellant's and VA's respective duties for obtaining evidence. The appellant was also asked to submit evidence and/or information in his possession to the AOJ. The Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The veteran was provided this notice in a March 2006 letter. The veteran is challenging the initial evaluation assigned following the grant of service connection for PTSD. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because service connection was granted for PTSD, the purpose of the VCAA had been fulfilled and VA's duty to notify for this issue was satisfied. Regarding the veteran's claim for service connection for heart disease, the VCAA duty to notify was satisfied by way of a letter sent to the appellant in April 2005 that fully addressed all four notice elements and was sent prior to the initial AOJ decision in this matter. The letter informed the appellant of what evidence was required to substantiate the claim and of the appellant's and VA's respective duties for obtaining evidence. The appellant was also asked to submit evidence and/or information in his possession to the AOJ. Additionally, regarding heart disease, the veteran was provided notice of rating criteria and effective date provisions that are pertinent to the appellant's claim in the March 2006 letter. See Dingess, supra. Any error regarding this notice was harmless given that service connection is being denied, and hence no rating or effective date will be assigned with respect to this claimed condition. VA also has a duty to assist the veteran in the development of the claims. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained service medical records, private medical records, Social Security Administration (SSA) records and VA medical records. The veteran set forth his contentions during the hearings before the Board. The appellant was afforded VA medical examinations in October 2003, February 2005, February 2006 and October 2006. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). PTSD Ratings for service-connected disabilities are determined by comparing the symptoms the veteran is presently experiencing with criteria set forth in VA's Schedule for Rating Disabilities, which is based as far as practical on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. Also, when making determinations as to the appropriate rating to be assigned, VA must take into account the veteran's entire medical history and circumstances. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). But since the veteran timely appealed the rating initially assigned for PTSD, the Board must consider entitlement to "staged" ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the appeal. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). The veteran's service-connected PTSD was assigned a 50 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411 for the period between September 3, 2003 and February 17, 2005. Since the veteran was awarded a 100 percent rating effective from February 17, 2005, the Board will only address entitlement for an increased rating between September 3, 2003, the date of the original service connection claim, and February 17, 2005. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives; own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) is a scale reflecting the "'psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness'" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (1994) at 32). A score of 51-60 represents "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co- workers)." Id. The Board finds that the veteran is entitled to an increased rating for service-connected PTSD for the period between September 3, 2003 and February 17, 2005. The evidence depicting the veteran's symptoms of PTSD during that time consists of an October 2003 VA Compensation and Pension Examination and the veteran's statements. The October 2003 VA examiner found that the veteran had intrusive thoughts during the day which interfered with his concentration and memory. He had nightmares, night sweats and disturbed sleep. He would awaken during the night, check locks and walk the perimeter inside the house. He isolated himself, stayed inside the house and avoided holidays. He also suffered from depression. He was frequently tearful and had shaky hands. He experienced episodes of sweating during the day and would sit in a hunched position hugging himself because of tension and anxiety. He was hypervigilant. He would avoid crowds and standing in line. He would sit with his back to the wall in view of entrances and exits. He lost his appetite for rice after Vietnam and avoided the news and violent television shows or movies. He experienced panic attacks which included profuse sweating, faintness, dizziness and trouble catching his breath. The veteran also had episodes of irritability and anger. The veteran was married for 34 years at the time of the examination. He and his wife were living in separate states. He had 6 children that lived with his wife. He indicated that he had a close relationship with his children. He did not socialize and did not have any close friends. During the examination, the veteran was oriented in all spheres. His affect was mildly blunted and his mood was mildly anxious. His thought process was linear and direct. There was no evidence of psychosis. His speech was normal in rate and rhythm. He had good eye contact. His judgment was fair and his insight was minimal due to lack of education and therapy. His memory and concentration were somewhat impaired by his anxiety and intrusive thoughts of combat. There were no signs of suicidal or homicidal ideation. The examiner found that his PTSD was moderate and assigned a GAF of 60. In the February 2005 VA Compensation and Pension Examination, the veteran indicated that he lost his desire to do anything. He indicated that this began about 4 to 5 years prior to the examination. The examiner indicated that the veteran continued to have the symptoms described in the October 2003 examination, but his most pronounced symptoms were depression, insomnia, loss of appetite, anergia, anhedonia, loss of concentration and fleeting thoughts that he would be better off dead. In a June 2007 hearing, the veteran testified that he began to miss work approximately 2 years prior to February 2005 because of his PTSD. The veteran testified that his symptoms of PTSD increased at that time so he could no longer work and he stopped taking care of himself. The Board notes that there is no evidence of treatment for PTSD or symptoms of PTSD in the evidence of record after the October 2003 VA Compensation and Pension Examination until the February 2005 VA examination. Affording the veteran the benefit of the doubt, the Board finds that the veteran is entitled to a 70 percent evaluation for the period between September 3, 2003 and February 15, 2005. Specifically, the veteran testified that he had occupational impairment during that time because he missed work due to his PTSD symptoms. He also had social impairment as evident by his lack of friends and isolating behavior. The veteran had depression and panic attacks and episodes of violence and anger. He indicated that he began to not take care of himself and could not handle stressful situations. Of significance is the opinion by the February 2005 VA examiner indicating that the veteran had consistent symptoms of PTSD since October 2003, with some symptoms that increased in severity. The Board finds that the veteran's symptoms in the October 2003 VA examination, such as daily intrusive thoughts causing interference with his concentration and memory, nightmares, disturbed sleep, depression, isolation behavior, tension, anxiety, hypervigilance and panic attacks, warrant a 70 percent rating during that time. The Board finds that the veteran is not entitled to a 100 percent evaluation between September 3, 2003 and February 15, 2005 because he did not have gross impairment in thought processes or communication during that time. He also did not have persistent delusions or hallucinations. The examiner indicated that the veteran's symptoms increased in the February 2005 examination and included loss of desire to live, loss of concentration and increased depression. The Board further notes that to the extent that the veteran's service-connected disability affects his employment, such has been contemplated in the assignment of the current 70 percent schedular evaluation. The evidence does not reflect that the disability at issue caused marked interference with employment or necessitated any frequent periods of hospitalization, such that application of the regular schedular standards is rendered impracticable. In fact, the veteran testified that he continued to work full time prior to February 2005. Hence, referral to the RO for consideration of the assignment of an extra-schedular evaluation under 38 C.F.R. § 3.321 (2007) is not warranted. Heart Disease The veteran asserts that he is entitled to service connection for heart disease. He asserts that his heart disease was caused by his service-connected PTSD. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). This may be shown by affirmative evidence showing inception or aggravation during service or through statutory presumptions. Id. To establish direct service connection for a claimed disorder, there must be (1) medical evidence of current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In this case, the VA and private medical records indicate that the veteran has congenital heart disease. June 2005 private medical records indicate the veteran has severe congenital heart disease with markedly enlarged bilateral left and right coronary cameral role fistulas as described to either right ventricular outflow tract or low pulmonary artery segments and mild to moderate pulmonary hypertension secondary to the congenital disease. In the October 2006 VA Compensation and Pension Examination, the examiner also diagnosed the veteran with congenital heart disease. Based on the medical evidence of record, the Board concludes that the veteran's heart disability is congenital. Congenital or developmental defects are not diseases or injuries within the meaning of applicable legislation for VA compensation purposes. 38 C.F.R. §§ 3.303(c). Service connection may be granted for congenital or hereditary diseases if initially manifested in or aggravated by service. VAOPGCPREC 82-90 (March, 5, 1985)(cited at 55 Fed. Reg. 45,711 (1990)); VAOPGCPREC 67-90 (September 27, 1988)(cited at 55 Fed. Reg. 43,253 (1990)). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2007). Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) reconciling Leopoldo v. Brown, 4 Vet. App. 216 (1993) and Tobin v. Derwinski, 2 Vet. App. 34 (1991). When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen, supra. As the veteran's heart disease was congenital, it was not caused by service or a service-connected disability. Therefore, the remaining issue is whether the veteran's congenital heart disease was aggravated by service or a service-connected disability. The only disability the veteran is service connected for is PTSD. As such, the Board will address whether the veteran's congenital heart disease was aggravated by service or by his service-connected PTSD. A pre-existing injury or disease is considered to have been aggravated by active service if there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Aggravation is not conceded where the disability underwent no increase in severity during service based on all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b); Falzone v. Brown, 8 Vet. App. 398, 402 (1995) (providing that the presumption of aggravation created by section 3.306 applies only if there is an increase in severity during service). A "lasting worsening of the condition" or a worsening that existed not only at the time of separation but one that still exists currently is required. Routen v. Brown, 10 Vet. App. 183, 189 (1997); see Verdon v. Brown, 8 Vet. App. 529, 538 (1996). The service medical records show that the veteran's congenital heart disease was not noted in the entrance examination in June 1968. The veteran did not report a congenital heart disease prior to service and the veteran's heart was clinically evaluated as normal. The in-service treatment records do not indicate treatment for or symptoms of heart disease in service nor do they provide a diagnosis of heart disease in service. The separation examination in June 1970 also does not show heart disease and the veteran's heart was clinically evaluated as normal. Due to the lack of diagnosis or symptoms of heart disease in service, the Board finds that the veteran's heart disease did not increase in severity in service. The evidence does not show that the veteran's heart disease was more severe at separation from service as it was when he entered service. As such, the Board finds that the veteran's heart disease was not aggravated in service. Regarding secondary service connection, the evidence of record does not show that his heart disability was aggravated by PTSD. The medical evidence of record does not show that the veteran's heart disease increased in severity because of his PTSD. In the October 2006 VA examination, the examiner opined that there was no evidence that PTSD contributed significantly to the congenital heart disease and there was no evidence that PTSD caused heart disease. The Board has previously concluded that the veteran's heart disease is congenital; therefore, it was not caused by PTSD. Additionally, based on the October 2006 VA examiner's opinion, the Board finds that the evidence of record does not show that the veteran's congenital heart disease was aggravated by PTSD. The Board has considered the veteran's contention that a relationship exists between his heart disease and PTSD. However, as a layman, without the appropriate medical training and expertise, he is not competent to provide a probative opinion on a medical matter such as etiology or aggravation. While a layman such as the veteran can certainly attest to his in-service experiences and current symptoms, he is not competent to provide an opinion linking that disability to service or a service-connected disability. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). The preponderance of the evidence is against the claim for service connection for heart disease because his heart disease was congenital and not caused by or aggravated by service or a service-connected disability. As such, the benefit-of-the-doubt rule does not apply and the veteran's claim for service connection for heart disease must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). ORDER A 70 percent evaluation for PTSD with generalized anxiety disorder and major depressive disorder is granted for the period between September 3, 2003 and February 17, 2005. Service connection for heart disease, including as secondary to PTSD with generalized anxiety disorder and major depressive disorder is denied. REMAND The veteran claims service connection for migraine headaches. He asserts that his migraines are directly related to service and to his service-connected PTSD. The Board finds that, based on the evidence of record, a remand is warranted to comply with VCAA notice requirements and to provide a VA medical examination. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the service medical records show that the veteran had frequent and severe headaches and dizziness in the June 1968 entrance examination. In February 1969, the veteran struck his forehead during a motor vehicle accident. After the accident, the veteran had complaints of headaches and dim vision. He was diagnosed with post-concussion syndrome. A VA Compensation and Pension Examination in October 2003 shows that the veteran had migraine headaches. The veteran reported that his headaches developed in service and after service they progressed in frequency and severity. He indicated that his headaches were associated with dizziness, throbbing, nausea, phonophobia and photophobia. The veteran testified that his headaches were triggered by stress and nervousness and he was no longer working because of his headaches and PTSD. He indicated that a physician told him that his headaches were caused by PTSD. VA treatment records in June 2004 show that the veteran had complaints of and received treatment for headaches. November 2004 VA treatment records show that the veteran was treated for headaches with salsalate. In January 2005, the veteran also had a diagnosis of headaches by a VA physician. The Board finds that a VA examination is warranted to determine if the veteran had a migraine headache prior to service and, if so, if his disability was aggravated by service. Additionally, a VA examination is warranted to determine if a migraine headache disability was incurred in service or was aggravated by a service-connected disability. Accordingly, the case is REMANDED for the following action: 1. The RO must review the claims file and ensure that all notification and development action required by 38 U.S.C.A. §§ 5102, 5103, and 5103A (West 2002) are fully complied with and satisfied with respect to the veteran's claim for service connection for migraine headaches on a direct basis as well as for service connection for migraine headaches secondary to PTSD. See 38 C.F.R. § 3.159. Such letter should also include an explanation as to the information or evidence needed to establish a disability rating and effective date for the claim on appeal. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 2. The RO should contact the veteran and request that he identify all VA and non-VA health care providers that have treated him for migraine headaches prior to service and after service. After securing the necessary releases, the RO should obtain those records not already on file and associate them with the file. 3. After the above has been completed to the extent possible, the veteran should be scheduled for a VA examination with the appropriate medical specialist to determine the etiology of the veteran's migraine headache disability. The claims file must be made available to and reviewed by the examiner in conjunction with the examination, and the examination report should reflect that such a review was made. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. The examiner should state whether the veteran's disability existed prior to service. If the headache disability existed prior to service, the examiner should state whether it was aggravated by service. The examiner should also state whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), causally or etiologically related to service. The examiner should also state whether his migraine headache disability was caused by or aggravated by his service-connected PTSD. If the examiner concludes that the veteran's migraine headaches disability was aggravated by service or by PTSD, the examiner should determine the increase in severity of the disability as well as distinguish between the level of aggravation and the natural progression of the disorder. If the examiner finds that there was aggravation, but can not quantify the degree of aggravation that fact should be noted in the report. The examiner should provide a rationale for any opinion provided. If the examiner is unable to provide an opinion, the examiner should explain why an opinion could not be reached. 4. The RO should then readjudicate the veteran's claim. If any benefit sought on appeal remains denied, the veteran should be provided with a supplemental statement of the case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issue. An appropriate period of time should be allowed for response by the veteran. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters 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. 2007). ____________________________ JOHN E. ORMOND, JR. Veterans Law Judge, Board of Veterans' Appeals ____________________________ A. P. SIMPSON Acting Veterans Law Judge, Board of Veterans' Appeals ____________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs