Citation Nr: 1311145 Decision Date: 04/04/13 Archive Date: 04/19/13 DOCKET NO. 10-46 218 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for headaches. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The Veteran had honorable, active military service from March 1972 to March 1975. His service from March 1975 to March 1976 was terminated under conditions other than honorable which constitutes a bar to an award of benefits based on a disorder incurred or aggravated during that second term. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Board notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the appellant's claim, known as Virtual VA. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. The record raises the issue of entitlement to service connection for residuals of a traumatic brain injury. This issue, however, is not currently developed or certified for appellate review. Accordingly, this matter is referred to the RO for appropriate consideration. 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 The Veteran asserts that he has chronic headaches which first began after he sustained a facial injury in December 1972. The Veteran's service treatment records indicate that he reported having a cold and headaches in June 1972. He was treated with Tylenol. In December 1972, the Veteran was treated for an injury to the mouth requiring sutures for mouth and lip lacerations. A December 1972 dental evaluation noted that the Veteran had suffered "a traumatic accident to anterior part of face." The Veteran was treated for respiratory infections in May 1972 and in July 1973. At a March 1976 separation examination the appellant reported a history of a head injury, and frequent headaches. A pertinent diagnosis was not offered. Examination revealed the appellant's head and neurological functions to be clinically normal. The Veteran's private treatment records include a November 2005 evaluation by his regular treating physician, Dr. D.P., for syncopal episodes manifested by feeling not "like himself," dizziness, faintness, and vision problems. Dr. D.P. included migraine headaches in the past medical history, noting that the Veteran "does have migraine headaches, which present with wavy lines at the peripheral fields of his vision." Dr. D.P. also noted that the appellant's "unusual feeling, dysphoria, disconnection with reality, dizziness (was) not associated with these headaches." In June 2008 the Veteran was afforded a VA examination. The examiner reported reviewing the service treatment records from March 1973 to April 1975 and noting that the Veteran had been treated for upper respiratory illness in July 1973. The examiner diagnosed the Veteran with migraine headaches, but opined that these headaches were less likely than not related to service because the transient respiratory illnesses the Veteran had in service were "common" and "independent viral illnesses that can cause headaches." In an addendum opinion, this examiner further noted that the Veteran's service treatment records showed only transient respiratory illness, also known as "a cold," and did not show any ongoing or chronic headache condition. The Veteran has also submitted a November 2008 letter from Dr. D.P. which states that the appellant suffers, in pertinent part, from headaches which he was unable to find any other cause for after an "aggressive work-up," other than the injury incurred in service, during which the appellant "fell face first and hit his head and actually knocked out a tooth." Dr. D.P. then stated that it was "more likely than not that some or all of these symptoms were caused by that incident." Based on the evidence discussed above, and the fact that the June 2008 VA examiner did not discuss the Veteran's in-service facial injury, an additional VA examination is needed in order to determine whether any current headache disorder is related to the injury to the face and mouth incurred in service in December 1972. VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). To be considered adequate, the medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). In this case, neither the June 2008 VA examiner nor the Veteran's treating physician appear to have reviewed the full service treatment records in order to provide a fully informed opinion regarding the connection between the appellant's service and any current headache disorder. The June 2008 VA examiner discussed the Veteran's in-service respiratory infections, but failed to review the treatment reports related to the facial injury that the Veteran incurred in December 1972. The examiner did not even appear to be aware of this injury and did not discuss whether it resulted in the appellant's current headache disorder. It is also unclear whether the headaches referenced in Dr. D.P.'s November 2008 letter are due to the headache disorder currently being claimed and referenced in Dr. D.P.'s November 2005 treatment record. As noted in 2005, Dr. D.P. reported that headaches were unrelated to the Veteran's other symptoms, such as dizziness. Under these circumstances, an examination of the Veteran to obtain a fully informed medical opinion addressing the nature and etiology of any current headache disorder, by a VA neurologist, based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly stated rationale, is needed to resolve the claim. McLendon, 20 Vet. App. at 83. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should schedule the Veteran for a new VA neurological examination to determine the nature and etiology of his headaches. The examining neurologist is to be provided access to the claims folders, a copy of this remand, and Virtual VA. The examining neurologist must specify in the report that the claims files and Virtual VA records have been reviewed. The examining neurologist must opine, in light of the examination findings and all relevant treatment records spanning from March 1972 to March 1975, whether any current headache disorder is at least as likely as not, i.e., there is a 50/50 chance, related to the appellant's military service during that term. The examining neurologist may consider the history reported in March 1976. The examining neurologist must specifically address the Veteran's December 1972 in-service facial injury, his reports of experiencing headaches regularly since service, and the November 2008 letter from Dr. D.P. The examining neurologist must provide both clear conclusions and a thorough and well-reasoned medical explanation supporting any opinion offered. If the examining neurologist is unable to provide an opinion, that fact must be stated and the reasons why an opinion cannot be provided explained. That is, the examining neurologist must specifically explain why the cause of any diagnosed headache condition is unknowable. 2. The RO/AMC must notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2012). 3. The RO/AMC must review any examination report and medical opinion to ensure that it is in complete compliance with the directives of this remand. If any report is deficient in any manner, the RO/AMC must implement corrective procedures. 4. Thereafter, the RO/AMC must readjudicate the claim. If the benefit sought is not granted, the appellant and his representative must be furnished with a supplemental statement of the case and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ DEREK R. BROWN 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) (2012).