Citation Nr: 1236192 Decision Date: 10/18/12 Archive Date: 11/05/12 DOCKET NO. 07-05 107 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for cherry angioma. 2. Entitlement to service connection for headaches, to include as secondary to an undiagnosed illness. 3. Entitlement to service connection for chronic fatigue syndrome. 4. Entitlement to service connection for fibromyalgia. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Lawson, Counsel INTRODUCTION The appellant is a Veteran who served on active duty November 1984 to November 1987 and from December 1990 to September 1992. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision of the Newark, New Jersey Department of Veterans Affairs (VA) Regional Office (RO). In September 2007, a Travel Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. In September 2008 and in June 2010, these matters were remanded for further development. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War. 2. The Veteran's cherry angioma is a known clinical diagnosis; was not manifest in service; and is not shown to be related to the Veteran's service. 3. The Veteran's tension and migraine headache disorder is a known clinical diagnosis; it was not manifested in service, and is not shown to be related to the Veteran's service. 4. The criteria for a diagnosis of chronic fatigue syndrome are not met. 5. It is reasonably shown that the Veteran has fibromyalgia. CONCLUSIONS OF LAW 1. Service connection for cherry angioma is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2011). 2. Service connection for headaches, to include as due to undiagnosed illness, is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1117, 1131, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2011). 3. Service connection for chronic fatigue syndrome is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2011). 4. Service connection for fibromyalgia is warranted. 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). It applies in the instant case, and provides that upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Inasmuch as service connection for fibromyalgia is being granted, there is no reason to belabor the impact of the VCAA on that matter; any notice defect or duty to assist failure is harmless. Regarding the other claims, the Veteran was advised of VA's duties to notify and assist in the development of the claims. A July 2004 notice letter provided him most of the necessary notice. While he did not receive complete notice prior to the initial determinations, a December 2006 letter provided the remainder of the essential notice prior to the readjudication of his claims. See Mayfield, 444 F.3d at 1328. The July 2004 notice explained the evidence necessary to substantiate his claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. The December 2006 letter informed the appellant of disability rating and effective date criteria. March 2010 and subsequent supplemental statements of the case (SSOCs) readjudicated the matters after the appellant and his representative were given an opportunity to respond. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (VCAA timing defect may be cured by the issuance of fully compliant notification followed by readjudication of the claim); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (discussing the rule of prejudicial error). The Veteran's available pertinent service treatment records (STRs) and available post-service treatment records have been secured. In November 2008, an attempt was made to obtain any additional STRs from Ft. Jackson, South Carolina, but that service facility indicated at the time that they were unable to locate any medical records for the Veteran. The RO arranged for VA examinations/medical opinions in August 2004, July and August 2005, October and November 2009, July 2010, July 2011, December 2011, and April 2012. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). The RO complied with the Board's September 2008 and June 2010 remands by verifying all periods of the Veteran's service; arranging for an exhaustive search for any additional STRs; obtaining VA medical records; obtaining VA examination reports as necessary; and readjudicating the claims. The examination reports are adequate for rating purposes as they show consideration of all pertinent evidence and are accompanied by an adequate explanation of rationale. The Board finds that the record as it stands is adequate to allow the Board to decide these matters, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any available pertinent evidence that remains outstanding. VA's duty to assist is met. B. Legal Criteria, Factual Background, Analysis Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). The Veteran served in the Southwest Asia Theater of operations during the Gulf War as shown by service personnel records (SPRs) received in February 2009. Compensation may be paid to any Gulf War Veteran "suffering from a chronic disability resulting from an undiagnosed illness (or combination of undiagnosed illnesses)." 38 U.S.C.A. § 1117. These may include, but are not limited to, headache signs or symptoms. 38 C.F.R. § 3.317(b). The chronic disability must have manifested either during active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011, and must not be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) IBS; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). To date, VA has identified only the three illnesses listed above as medically unexplained chronic multisymptom illnesses. 38 C.F.R. § 3.317(a)(2)(i)(B)(1)-(3). For VA purposes, the diagnosis of chronic fatigue symptoms requires: (1) the new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least 6 months, and (2) the exclusion, by history, physical examinations, and laboratory tests, of all other clinical conditions that may produce similar symptoms, and (3) 6 or more of the following: (i) acute onset of the condition, (ii) low grade fever, (iii) nonexudative pharyngitis, (iv) palpable or tender cervical or axillary lymph nodes, (v) generalized muscle aches or weakness, (vi) fatigue lasting 24 hours or longer after exercise, (vii) headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state), (viii) migratory joint pains, (ix) neuropsychologic symptoms, and (x) sleep disturbance. 38 C.F.R. § 4.88a (2011). For VA compensation purposes, the diagnosis of fibromyalgia (sometimes called fibrositis, primary fibromyalgia syndrome, or myofascial pain syndrome) requires the presence of widespread musculoskeletal pain and tender points. Additional findings may also be present: fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms. Widespread pain is defined as pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. VA fibromyalgia examination worksheet (2007). Accordingly, under 38 C.F.R. § 3.317, service connection may be granted on a presumptive basis if there is evidence (1) that the claimant is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2011; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. §§ 1117 , 1118; 38 C.F.R. § 3.317. When a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. § 1110 is necessary. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). To prevail on the issue of service connection, there must be medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, as well as in "Virtual VA" (VA's electronic data storage system, which at this time contains no pertinent evidence or information), with an emphasis on the evidence relevant to the matter on appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. The Veteran's STRs, including his April 1991 re-deployment and December 1993 Demobilization examination reports, are silent for any complaints, findings, treatment, or diagnoses of cherry angioma or chronic fatigue syndrome. The Veteran was seen for a headache following head trauma in August 1985. He stated that a hatch door struck his head the prior day. He denied loss of consciousness and his neurological status was intact/within normal limits. A January 1986 STR notes redness and itching of the Veteran's face after crawling through brush and an assessment of allergic reaction. June 1986 STRs note redness and hives following insect bites. A December 1991 STR notes complaints of erythema and scaling of the Veteran's scalp and face; the assessment was seborrheic dermatitis. The Veteran denied (or did not report) pertinent symptoms on service and National Guard examinations in July 1987, September 1988, December 1990, April 1991, July 1991, and April 1993; his musculoskeletal system, skin, neurologic, and psychiatric systems were normal on clinical evaluations at such times. He reported face flaking for one week on December 1991 demobilization examination; on clinical evaluation his skin was normal. In an April 1993 National Guard report of medical history, the Veteran denied having or having had skin disease and headaches ; his skin and neurological system were normal on clinical evaluation. On November 2002 private evaluation, the Veteran was found to be healthy except for hearing loss complaints. His head and neck were normal on physical examination. In his March 2004 claim, the Veteran indicated that he had the onset of skin rashes in January 1991, headaches in December 1994, and fibromyalgia and muscle and joint pain in September 1993. He stated that many of his claimed conditions resulted from serving in the Persian Gulf War; that after being activated for Desert Shield, he came back with various illnesses. On August 2004 VA neurology examination, it was noted that the Veteran had been complaining of chronic fatigue syndrome, headaches, and symptoms of fibromyalgia off and on since he served in the Gulf War. The headaches were mostly bitemporal, bifrontal, throbbing, and pounding, and then become a dull ache with pressure in the occipital region associated with phonophobia. He complained of chronic stiffness of muscles starting from his head and neck down to his back, and reported that he had been evaluated by a rheumatologist and told that he had fibromyalgia. He complained of a sleep disorder with fragmented broken sleeps, and insomnia, and due to the anxiety and stress, he was on Ambien. He also complained of short term memory problems since he had been in the Persian Gulf War. On neurologic examination, recall in 3 minutes and 5 minutes was 2/3. Tenderness to palpation was noted in his mid-dorsal and lower dorsal spine and also in the lower lumbosacral area, as well as in both upper and lower extremities and in back muscles. The diagnoses were chronic migraine and tension headaches; chronic fatigue syndrome; fibromyalgia; mild short term memory loss; and sleep disorder (insomnia). On August 2004 VA Gulf War examination, the Veteran noted a history of skin problems since the Gulf War. He reported noticing red, nontender, nonpainful lesions that occur especially on the trunk and also on the back. On examination, the Veteran had 10 small 1-millimeter lesions that were slightly raised over his anterior and posterior thorax. The diagnoses were cherry angioma; and fibromyalgia by history. On August 2004 VA chronic fatigue syndrome examination, the Veteran reported that he believed that his aches and pains started during Persian Gulf service in September 1991. In 1991, he noticed that he could not play basketball like he used to be able to do and tired easily climbing a flight of steps. He slept 1-2 hours, on average, awakening frequently; he never had a good night's sleep. He complained of shoulder aches and low back pain. Extra work around the house increased his fatigue for 2 days. He had a headache during the examination and denied migrating joint pain. On examination, all joints were tested and were normal except for tenderness and some swelling of his right 5th proximal interphalangeal joint. All muscle groups were tested and found to be of normal strength except for his left shoulder due to some shoulder pain. Four of 18 fibrocytic points were mildly tender; none made the Veteran flinch. The impression was that the Veteran had some symptoms suggestive of chronic fatigue, but did not meet the criteria, as he only had a headache and post-exercise fatigue. He also did not meet the criteria for fibromyalgia. He gave different times as to when he thought his symptoms started;, he felt that the chronic fatigue had started sometime between 1995 and 1997, with gradual onset. He estimated that his joints fatigued 50 percent faster than those of normal people. Joint pain was not a problem. On August 2005 VA chronic fatigue syndrome examination, the Veteran reported that after being seen in sick bay in service in September 1991, he was transferred to a different job because of increased tiredness. He felt his tiredness may have started in March 1991, but did not recall if it started gradually. The fatigue was most notable in 1995. He reported that his muscles were too sore to exercise and that if he did exercise, they would ache for one or two days afterwards. He indicated that his headaches started in 1995. On physical examination, 9 of 18 fibrocytic points were judged by the Veteran to be tender and only one made him flinch. No pharyngitis or exudate was seen, and no cervical, submental, supraclavicular, or axillary lymph nodes were found. The examiner noted that the Veteran denied frequent fevers, pharyngitis, acute onset of symptoms, migrating joint aches, and troublesome cervical axillary lymph nodes. Thus, he did not meet the criteria for chronic fatigue syndrome. The examiner indicated that the Veteran's depression was a disqualifier for a diagnosis of fibromyalgia. The examiner agreed with the neurologist that the Veteran had many symptoms consistent with diagnoses of fibromyalgia and chronic fatigue syndrome, but did not meet the criteria for such diagnoses. It was noted that the Veteran's ulcerative colitis could be causing some of his fatigue and depressive symptoms. In his February 2007 Substantive Appeal (on VA Form 9) the Veteran asserted that he has 8 of 18 pressure points consistent with fibromyalgia syndrome, and has chronic fatigue that has not improved. He claimed he has chronic headaches from serving in Desert Storm. He indicated that he mentioned cherry angioma at his exit physical in December 1991, and was issued medication for his face, neck, and chest. At the September 2007 Travel Board hearing, the Veteran testified that he was told that he had rashes at Ft. Jackson in January 1992. His initial diagnosis of cherry angioma was made on July 2005 VA examination. He had not been told he had chorioangioma in service. He described the effects of his fibromyalgia. He described a headache in service when he was jolted and his head snapped back in his helmet, noting it was documented in Ft. Hood medical records. He did not have headaches except for that one day in service. In September 2008 the Board remanded the case for medical opinions regarding a nexus between any current skin disability and skin problems for which the Veteran was seen in service; whether a current headache disability is related to his service; and whether or not he has diagnoses of chronic fatigue syndrome and fibromyalgia. On October 2009 VA neurology examination, mixed headache disorder was diagnosed. The major component was triggered by muscular contractions, followed by migraine. On October 2009 VA skin examination, the Veteran's skin on his head, neck, face, torso, upper and lower extremities, and back was clear and the diagnosis was no skin condition found at the time. On November 2009 VA fibromyalgia examination, the Veteran indicated that he had the onset of fatigue over a 3-year period from 1992 to 1995, and that his symptoms waxed and waned. He had frequent fevers, and infrequent upper respiratory infections. On examination, no lymphadenopathy was found in the cervical, supraclavicular, axillary, or epitrochlear regions. His ankles were diffusely tender and his left shoulder was quite tender, and became fatigued. The examiner indicated that the Veteran did not have chronic fatigue syndrome when he was seen in 2005, and that his depression is a disclaimer for diagnoses of either chronic fatigue syndrome or fibromyalgia. For chronic fatigue syndrome, he had frequent headaches, poor sleep, fatigue following exercise, and joint pain (nonmigratory). He had near total body ache and thus probably had muscle aches. Thus, he appeared to have 4 or 5 rather than the 6 symptoms required for a diagnosis of chronic fatigue syndrome. Some of his fatigue started fairly abruptly in Iraq. Thus, that is why the examiner said 4 or 5 symptoms, as it was not clear how quickly the fatigue started. His depression and posttraumatic stress disorder were a disclaimer for a diagnosis of chronic fatigue syndrome. In June 2010, the Board remanded this case for opinions as to whether any cherry angioma found is related to service; whether the Veteran's current headache disability is related to his service; and for an opinion as to whether the Veteran's depression was strictly a psychiatric disability and not attributable to chronic fatigue syndrome. On July 2010 VA fibromyalgia examination, the Veteran reported that his worst pain was in the trapezius muscles, extending into his neck. His other pains were in his left shoulder, elbow, and wrist, along with his low back, knees, and ankles. Two weeks prior he had lifted detergent, which weighed a few pounds, with his left arm, and brought it up the steps, and his shoulder hurt for 20 minutes afterwards. He had a low ache in his left arm and shoulder for several days. He indicated that using his painful areas made his pains worse. Many of his labs had been checked in November 2009 and they seemed normal. On examination, the Veteran judged 13 of 18 fibrocystic tender points to be really tender. Range of motion in his ankles and knees was normal, with some pain. With left and right shoulder abduction, pain started at 90 degrees, with motion beyond that causing increasing pain. Extension of the neck was to 20 degrees with increasing pain, and flexion was to 0 degrees, at which point the Veteran declined further flexion due to increasing pain. Rotation to the right was 40 degrees and to the left 45 degrees. The diagnoses were depression and/or adjustment disorder; and fibromyalgia resulting from his war experience in the Gulf War. On July 2010 VA psychiatric examination, it was explained by the examiner that the Veteran has a psychiatric diagnosis of mood disorder with depressive features, and that it is a direct consequence of his irritable bowel syndrome/irritable colon, ringing in his ears, and headaches. His irritable bowel syndrome/irritable colon contributes to approximately 45 % of his depression; his ringing in his ears contributes approximately 45 %; and his headaches contribute approximately 10 % to his overall depression. In the examiner's opinion, the Veteran's depressed mood was clearly and causally related to the 3 medical conditions specified. All noted depressed mood was deriving from his headaches, irritable bowel syndrome/irritable colon, and tinnitus. On July 2010 VA skin disease examination, the Veteran's electronic record and claims folder were reviewed. The Veteran reported that he had skin lesions since the Gulf War in 1991, when he did lifeguard duty, and that they were getting progressively worse. On examination, there were multiple 2-3 millimeter, red, slightly raised lesions found on various parts of his body. The diagnosis was cherry angioma. The examiner indicated that it was a chronic condition and that there was no causal relationship between such and the Veteran's service. The lesions were vascular proliferations, and not much was written in the available medical literature regarding the factors that contribute to the formation of such lesions. On July 2010 VA neurological disorders examination, the Veteran's claims folder was reviewed and the examiner knew that he was being asked to evaluate the Veteran for headaches and whether they are service-connected. The Veteran gave a history of head trauma in service when a hatch door latch broke and the hatch hit him in the head. Some small scrapes on top of his head were reported. At the time, the Veteran had headaches with dizziness for 24 hours. He was treated with analgesics and discharged. There were no stitches or laceration injury and an X-ray was not required. There was no history of skull fracture. There was no loss of consciousness but he had been stunned and dazed for a few seconds. There is no record in the service medical records of follow-up for residuals of the injury (to include headache). The Veteran stated that subsequently he experienced headaches intermittently for the last several years. The headaches were mostly in the occipital region with a migraine component in the bifrontal region. The diagnosis was chronic tension and migraine-type headaches. The examiner concluded that because there was no follow-up for the headaches from 1985 to 2009, it was less likely as not that the current tension and migraine type headaches are related to the headaches in service. On April 2012 VA chronic fatigue syndrome examination, the examiner noted that the Veteran had severe depression and active ulcerative colitis, with associated fatigue. The examiner stated that the Veteran has symptoms that are included in the criteria for a diagnosis of chronic fatigue, but that these were most likely caused by his depression and active ulcerative colitis and were less likely than not due to chronic fatigue syndrome. He indicated that at least 6 of the 10 chronic fatigue syndrome symptoms were shown. Cherry angioma is a known clinical diagnosis. As it is a known clinical diagnosis, it cannot be service-connected as due to an undiagnosed illness. Instead, the Board must consider whether it is otherwise related to the Veteran's service. Combee v. Brown, 34 F.3d 1039, 1042. Notably, cherry angioma were manifested in service or clinically noted in the initial postservice years (including on National Guard periodic examination). The Veteran clarified at the September 2007 Travel Board hearing that while he was told he had rashes on service discharge examination he was not then told that he had chorioangioma. This clarification is consistent with the notation of skin rash on December 1991 demobilization examination (when there was no mention of cherry angioma). [Notably, the matter of service connection for rashes/hives was decided in a previous Board decision, and is not for consideration herein.] Cherry angioma was initially diagnosed on August 2004 VA examination, many years postservice. The July 2010 VA dermatology examiner opined that there was no evidence that such disability is related to the Veteran's service (and that the etiology of cherry angiomas is largely unknown). That is the only competent evidence regarding the etiology of the Cherry angiomas. As it is by a dermatologist (with expertise in that field of medicine) who cites to factual data and explains the rationale for his opinion it is probative and persuasive evidence in the matter at hand. The Veteran argues that his Cherry angioma disability is related to his Persian Gulf service. However, he has not submitted any medical evidence supporting this contention. The etiology of a specific dermatologic diagnosis (in the absence of continuity of symptomatology) is a complex medical question. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran is a layperson with no demonstrated expertise in the matter. He has presented no supporting medical opinion or medical literature evidence. His own opinion is not competent evidence in the matter. The Veteran's cherry angioma is a known clinical diagnosis; it was not manifested in service, and there is no objective evidence of postservice continuity of manifestations of such disability. The competent evidence in this matter is against a finding that the Cherry angioma might be related to service. Accordingly, the preponderance of the evidence is against this claim. The Veteran's current headaches are attributed to a known clinical diagnosis (tension and migraine headaches). Therefore, the claim of service connection for the headaches does not fall within the purview of the presumptive provisions of 38 C.F.R. § 3.317. The Veteran is shown to have had had one headache in service, upon being struck on the head with a hatch door. Notably, he testified at the September 2007 hearing that the headache in service resolved quickly and that he had no further headaches in service. Accordingly, service connection for a headache disorder on the basis that such disorder became manifest in service and persisted is not warranted. Postservice, the Veteran's migraine and tension headaches were first noted on VA neurology examination in August 2004. On July 2010 examination the examiner opined (in essence) that because there was no continuity of headache complaints after the one occasion of the head injury in service, any current headaches are unrelated to the veteran's service/injury therein. The provider's opinion is accompanied by explanation of rationale with citation to factual data, and is probative evidence in this matter. Because there is no competent evidence to the contrary, it is persuasive. Specifically, while the Veteran may believe that his headaches are somehow related to service his service, whether or not such an insidious process as headaches may, in the absence of continuity of complaints/symptoms (as the Veteran has testified at the hearing), be related to a remote event(s) is a complex medical question. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Once again, it is noteworthy that the Veteran is a layperson with no demonstrated medical expertise. The preponderance of the evidence is also against a finding that the Veteran meets the criteria for a diagnosis of chronic fatigue syndrome. While fatigue has been noted, it has been attributed to other clinical diagnoses; specifically, an April 2012 VA examiner opined that symptoms that would serve to establish a diagnosis of chronic fatigue syndrome are most likely caused by the Veteran's depression and active ulcerative colitis. Under 38 C.F.R. § 4.88a (2) such a finding establishes the Veteran does not meet the criteria for a diagnosis of chronic fatigue syndrome. In the absence of competent evidence of a current medical diagnosis of chronic fatigue syndrome, there is no valid claim of service connection for such disability. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, service connection for chronic fatigue syndrome is not warranted. Fibromyalgia was diagnosed on August 2004 VA neurology examination; the Veteran had widespread tenderness at the time supporting the diagnosis. An August 2004 VA Gulf War examination report noting a history of fibromyalgia is not probative of whether the Veteran has a diagnosis of such disability, as the Veteran was not examined for that purpose at the time. On August 2004 VA chronic fatigue syndrome examination, the examiner opined that the Veteran did not meet the criteria for a diagnosis of fibromyalgia (only 4 of 18 fibrocytic points were tender). However, there was insufficient information given determine whether the fibrocystic points were widespread. The August 2005/November 2009 VA examiner incorrectly noted that depression was a disqualifier for a diagnosis of fibromyalgia, and so his opinion that the Veteran does not meet the criteria for a diagnosis of fibromyalgia because he has depression has no probative value. On VA examination in July 2010, the Veteran had widespread musculoskeletal pain, and the examiner concluded that he meets the criteria for fibromyalgia. Accordingly, the evidence reasonably shows that the Veteran has such diagnosis. As fibromyalgia is a multisymptom illness which may be service connected on a presumptive basis under 38 U.S.C.A. § 1117, because the Veteran is shown to be a Persian Gulf Veteran, and because the fibromyalgia is manifest to a degree of 10 percent, service connection for the fibromyalgia is warranted. ORDER Service connection for cherry angioma is denied. Service connection for a headache disorder, to include as due to undiagnosed illness, is denied. Service connection for chronic fatigue syndrome is denied. Service connection for fibromyalgia is granted. ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs