Citation Nr: 1314661 Decision Date: 05/03/13 Archive Date: 05/15/13 DOCKET NO. 12-28 817 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for a headache disability. ATTORNEY FOR THE BOARD J. Young, Associate Counsel INTRODUCTION The Veteran had active duty service from June 9, 1975 to June 30, 1975. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. FINDING OF FACT There is no competent evidence of record that the Veteran has a headache disability that is etiologically related to active service. CONCLUSION OF LAW The criteria for service connection for a headache disability have not been met. 38 U.S.C.A. §1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this matter, substantially compliant notices were sent in August 2010 and September 2010 to the Veteran. In a September 2010 response, the Veteran indicated that he had no other information or evidence to give VA to support his claim. With regard to the duty to assist, the RO obtained service treatment records (STRs), personnel records, and post-service medical records, including medical records from Veteran's private physicians. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file, including the Social Security Administration (SSA) records, and the Veteran has not contended otherwise. The Veteran was not afforded a VA examination; however, the Board finds that a medical opinion on the question of service connection for a headache disability is not required because there is insufficient evidence establishing that the Veteran suffered an event, injury or disease in service or that a headache disability may be associated with service. 38 C.F.R. § 3.159(c)(4). All known and available records relevant to the issue on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. II. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). The Veteran contends that his headache disability was incurred during active military service in June 1975 and continues "off and on." See July 2010 claim. The Veteran also contends that symptoms related to a headache disorder resulted in his discharge from basic training. In February 1975, the Veteran received a medical examination upon enlistment into service and a subsequent pre-training physical inspection on June 9, 1975; both examinations cleared the Veteran for service and neither documented a headache disorder. See STRs. The Veteran's STRs do not include documentation of a separation medical examination; however, the Veteran signed a Statement of Medical Condition on June 30, 1975, which indicates that a separation examination occurred on June 11, 1975 and that "there has been no change in my medical condition" since "my last separation examination." The Veteran asserts that he suffered from severe headaches on multiple occasions during service in June 1975 and reportedly continues to suffer from headaches. The Board acknowledges the Veteran's assertion that he had headaches during and since service, and finds that he is competent to make such an assertion. See Jandreau, 492 F.3d at 1372. However, the Board does not find the Veteran's statements to be credible with respect to experiencing headache symptoms continuing since service. In analyzing credibility, the Board is justified in taking into account multiple factors, including possible bias and inconsistencies within the record. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), First, the Veteran's statements are inconsistent with his report at separation from service on June 30, 1975, that there had been no change in his medical condition since the last examination on June 11, 1975. On June 9, 1975, no physical defects were noted. In addition, his assertions are inconsistent with his denial of or the absence of headaches in post-service treatment records. In December 2008, the Veteran specifically denied headaches. See Dr. P. records. The Veteran reported receiving treatment or evaluation for "all conditions" at the VA Hospital in Charleston, South Carolina from 2008 until 2012. Those records are devoid of reference to, complaint of, or treatment for headaches. June 2009 VA medical records indicate that the Veteran had no history of head trauma or headaches and no significant related problems. In September 2009, the Veteran reported to a VA psychiatrist that he was discharged from service because he developed severe headaches. The Veteran did not receive a medical discharge from service and his STRs are devoid of reference to, complaint of, or treatment for headaches. The past medical history detailing a computerized problem list did not include a diagnosis of headaches. In a June 2010 record, the Veteran denied a history of head trauma or headaches. In a Mental Health Initial Evaluation note dated 6 days later, the Veteran reported that he was not given a medical discharge, but he experienced severe headaches during service and was in the military for less than one month. In an October 2011 statement, a VA physician wrote that the statement was being written "with the permission [and] at the request of the patient....In addition to the medications that he is prescribed from the Clinic he also takes over the counter analgesics for his head aches." March 2012 VA medical records included headaches on the active problem list with a date of October 2011. Later in March 2012, the Veteran denied a history of "head trauma and head aches with no significant problems." Records from the Social Security Administration include the Veteran's response to the instruction to list "all of the physical or mental conditions...that limit your ability to work." Headaches were not included in that list. He identified the VA physician who provided the October 2011 statement as the medical provider who would have pertinent treatment records and detailed the medical conditions for which he was treated. Again, headaches were not included in that list. Over the course of receiving consistent treatment and evaluation from VA medical service providers and private care providers, the Veteran reports pain and other symptoms for an array of medical conditions, but failed to report any symptoms related to a headache disorder. The only indication in the post-service medical records that the Veteran suffers from headaches is the October 2011 statement from a VA physician which noted that he takes over the counter medication for headaches. Headaches first appeared on the problem list in VA medical records after that statement. The VA physician did not indicate a possible etiology of the headaches and specifically noted that the statement was provided at the Veteran's request. The October 2011 physician's letter is not a medical opinion, nor does it provide a medical nexus. The October 2011 letter is not indicative of whether the Veteran's reported headaches are related to service or whether the Veteran has a chronic headache disorder. That statement appears inconsistent with the more objective medical records and since it was provided at the Veteran's request, may have a natural bias. In addition, the Veteran specifically denied a history of headaches in March 2012. Therefore, the October 2011 physician's letter is not sufficient to corroborate the Veteran's claim. Thus, the only evidence of a current headache disability is the Veteran's own assertions, which the Board has not found credible. In the absence of proof of a present disability due to disease or injury, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. See 38 U.S.C.A §5107. ORDER Service connection for a headache disorder is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs