Citation Nr: 1326510 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 06-34 359 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a migraine headache disorder. 2. Entitlement to service connection for a nonmigraine headache disorder. 3. Entitlement to an initial rating greater than 10 percent for a lumbar spine disability. 4. Entitlement to an effective date earlier than April 8, 2009, for the award of service connection for a lumbar spine disability. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. Snyder, Counsel INTRODUCTION The Veteran served on active duty from January 1978 to December 1980. The Veteran had a subsequent period of service with a reserve component. This appeal comes before the Board of Veterans' Appeals (Board) from an October 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In July 2010 and September 2012, the Board remanded the present matter for additional development and due process concerns. The Veteran initially filed service connection for a migraine headache disorder. However, the evidence indicates that the Veteran has been diagnosed with multiple headache disorders. Nonetheless, because the Board finds the Veteran's statements suggest intent to apply for service connection for each headache disorder the Board has characterized the issues on appeal as shown on the first page of this decision. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The issues of entitlement to an increased initial rating and earlier effective date for the lumbar spine disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The most probative evidence of record shows that the Veteran's migraine headache disorder began in service. 2. The most probative evidence of record shows that the Veteran's nonmigraine headache disorders did not begin in service, are not causally related to service, and are not caused or aggravated by a service connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a migraine headache disorder have been met. 38 U.S.C.A. §§ 1111, 1131, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 2. The criteria for service connection for nonmigraine headache disorders have not been met. 38 U.S.C.A. §§ 1111, 1131, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Law Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may also 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). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection may be established on a secondary basis for a disability which is proximately due to, or aggravated by, service connected disease or injury. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment; or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b). Thus, there is a rebuttable presumption of soundness unless a condition is noted at entry. VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003); see also Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. In adjudicating the claims below, the Board has reviewed all of the evidence in the Veteran's claims file including those found in Virtual VA. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the Veteran's claims folder shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Facts The November 1977 enlistment examination reflects the Veteran's history of "severe or frequent headaches." The record clarifies that the Veteran was reporting frequent headaches which were not associated with nausea or vomiting and which did not cause him to miss work. No disorder was diagnosed. A February 1978 service treatment record reflects the Veteran's history of headaches with pain over the frontal and temple regions. After examination, the Veteran was diagnosed with allergic-like rhinitis. June and July 1979 treatment records reflect the Veteran's history of cramping in the shoulder. The Veteran denied injury. He reported headaches within the past several months. A November 1979 treatment record reflects the Veteran's history of nausea, slight fever, headache, and vomiting with blood. After examination, he was assessed with a bleeding ulcer. January 1980 treatment records reflect the Veteran's history of headache, throat trouble, and slight dizziness. The Veteran explained that he felt like he had a cold and post-nasal drip. After examination, he was assessed with an upper respiratory infection. The diagnosis was then amended to sore throat. A September 1980 treatment record reflects the Veteran's history of headaches in the temple region since having dental work. The record notes that the dental work was the source of the pain. The Veteran was assessed with a migraine headache. A December 1980 "statement of option" indicates that the Veteran did not desire a separation medical examination. Post-service a September 1981 VA dental treatment record reflects the Veteran's history of headaches in the upper left temple area since having a tooth extracted in service, approximately one year earlier. He reported that he underwent tests at a hospital but no cause of the headaches was found. A September 1981 private inpatient treatment record reflects the Veteran's history of "severe headaches" for three months. After examination, the Veteran was assessed with migraine headaches. A November 1981 VA dental treatment record reflects the Veteran's history of left temporal headaches. A September 1982 reserve examination record reflects the Veteran's history of "frequent or severe headache." The Veteran explained that the headaches started after a tooth extraction in September 1980. The record also reflects the Veteran's history of a "trick or locked shoulder." The record notes that the Veteran reported left shoulder crepitus and denied a history of dislocation. A March 1983 VA medical certificate reflects the Veteran's history of headaches since 1980. The Veteran described the headaches as throbbing in the left temple for approximately 45 to 50 minutes. He was diagnosed with chronic headaches without neurological findings. An April 1983 VA examination record reflects the Veteran's four-year history of headaches. The Veteran explained that the headaches occurred almost daily and that approximately three times a week, the headache was "bad enough to force him to bed, sometimes with nausea." The impression was "history compatible with migraine headache." September 1994 private emergency treatment records reflect the Veteran's history of severe headache around the left temple. The Veteran reported a similar headache one to two years earlier. The records indicate that the Veteran had an intermittent history of the same headache for the previous 10 years. The Veteran was initially assessed with muscle tension headache. The final diagnosis was migraine headaches. A November 1995 private emergency treatment record indicates that the Veteran sustained a head injury. Subsequent private emergency treatment records reflect treatment for headaches diagnosed as acute migraine headaches. A May 1996 private consultation report reflects the Veteran's history of severe headaches for the previous 2.5 months. He explained that his headaches had become worse since the head trauma in October 1995. The Veteran also reported a history of sustaining injuries, and losing consciousness, as a result of a post-service motor vehicle accident in 1983. The physician noted that he treated the Veteran's brother for "fairly typical cluster headaches." The physician determined that the Veteran appeared to have vascular headaches with superimposed tension component. The physician explained that the reported headaches lasted too long to make a diagnosis of a cluster headaches, though there were features that sounded like a cluster headache. After further examination, the Veteran was assessed with migraines. See May 1996 K.P. medical records. The physician subsequently diagnosed chronic post-traumatic headaches in August 1997, chronic migraine headaches exacerbated by head trauma incurred at work in October 1997, combination headaches with a clear post-traumatic component in November 1997, and migraine with marked exacerbation in January 1998. A February 1998 private emergency treatment record indicates that the Veteran was treated for head trauma following a motor vehicle accident. Private treatment records dating after the motor vehicle accident reflect findings of worsening of migraines/post-traumatic headache syndrome as a result of the accident. See February 1998 B.C.C. treatment record; February 1998 K.P. treatment record. A May 1998 private neurological treatment record reflects the Veteran's history of headaches since age 22. However, the Veteran clarified that although he had headaches prior to the 1995 injury, the headaches were "nothing like" his current headaches. The Veteran also reported sustaining a facial fracture as a result of a post-service motor vehicle accident in 1983. A July 1998 statement from a private physician reflects the physician's determination that the Veteran's headaches were clearly exacerbated by a work accident and then the post-service motor vehicle accident. See July 1998 K.P. medical statement. An April 1999 private neurological treatment record reflects the Veteran's history of headaches since "shortly after" a head injury in October 1995. The Veteran reported that the headaches were associated with throbbing, nausea, photophobia, phonophobia, and blurring of vision. He was diagnosed with migraine and tension headaches, exacerbated by head injury in 1995. See A.E. treatment record. A March 1999 private hospital treatment record reflects the Veteran's history of a headache which was associated with nausea. He reported a history of "this type of headache" for three to four years. The record reflects a diagnosis of vascular headache. A July 1999 disability evaluation reflects the Veteran's history of symptoms including headaches since accidents in 1995 and 1998. A February 2001 application for disability benefits reflects the Veteran's history of migraines which were aggravated by a post-service 1998 motor vehicle accident. The Veteran reported that the migraines were associated with a sharp pain in the left temple, blurred vision, nausea, and vomiting. Subsequent records associated with the claim for benefits reflect the Veteran's testimony that the headaches began in 1996 after a workplace accident and increased post-service in 1998 after the motor vehicle accident. A July 2001 Disability Determination questionnaire reflects the Veteran's history of headaches since 1982. A May 2001 VA treatment record reflects the Veteran's history of migraines for 10 years. He was diagnosed with migraines. A subsequent May 2001 VA treatment record reflects the Veteran's history of migraines for "more than 10 years." A June 2001 VA treatment record reflects the Veteran's history of migraines for "10 to 12 years." He described the migraine headaches as "severe sharp pain in the left temple that was associated with nausea, vomiting, photophobia, and phonophobia. He explained that his headaches increased in severity after a work-place injury to his head in 1996 and then increased in severity again after a motor vehicle accident in 1998. A September 2001 VA treatment record reflects the Veteran's history of headaches since sustaining injury to his head and neck after a motor vehicle accident. Subsequent medical records reflect continued histories and treatment for these headaches, diagnosed as migraine headaches or cluster headaches. The records also reflect a determination that the Veteran had a separate headache disorder, diagnosed as cervical/occipital headaches, which was likely caused by his cervical spine degenerative disc disease or occipital neuralgia. See, e.g., April and June 2009 and May 2010 VA treatment records. In October 2006, the Veteran reported chronic migraine headaches since basic training. The Veteran attributed the migraine headaches to a pinched nerve in the back and neck which was caused by a dislocation of the left shoulder. In May 2007, the Veteran's sister reported that the Veteran had migraine headaches since 1978 after entering the military. February and July 2009 private treatment records reflect the Veteran's history of migraine headaches "for years." The Veteran also reported a history of "severe trauma" in the 1980s or early 1990s. After several treatment sessions, the private chiropractor determined that a "major component" of the Veteran's headaches was a misalignment of the cervical and upper thoracic spine and cervical disc disease. The chiropractor added that the shoulder injury sustained in basic training was the direct cause of the headaches and cervical spine condition. See B.C.C. treatment records. The April 2010 hearing transcript reflects the Veteran's testimony that his migraine headaches began during service. He denied migraine headaches prior to service. He explained that he believed the migraine headaches were related to injury during basic training. He explained that he ran into a door, separating his shoulder, and twisting his pelvis, lower back, and neck. A January 2012 VA examination record reflects the Veteran's history of headaches since he injured the left shoulder during service. The Veteran reported that he did not receive treatment for the headaches at that time. The record notes that the Veteran was initially diagnosed with migraines and later additionally diagnosed with cluster headaches. After examination and review of the evidence, the examiner determined that the headache disorders were less likely than not incurred in or caused by service, to include the reported in-service injury. The examiner explained that although the service medical records showed treatment for headaches, the headaches were part of other conditions, namely upper respiratory infections and other infections, and there was "no evidence" of migraine or cluster headaches in service based on the service medical records. The examiner noted that there was no medical documentation of a headache disorder until the mid to late 1990s and the data in the claims file "clearly show" that the headache started after the accidents that he had in the mid to late1990s. The examiner found this determination was confirmed based on the social security documentation. The examiner added that the providers who issued the letters in support of a nexus between service and the headaches were the same providers who provided opinions to SSA that the conditions began in the 1990s. In sum, the examiner found the Veteran's post-service injuries and occupation were the most likely causes of these conditions. The examiner also found that it was less likely that the headache disorders were caused or aggravated by a service-connected disability, to include the reported right shoulder injury. The examiner noted that although the Veteran had shoulder symptoms in service, there was no evidence of headaches at the time of the shoulder symptoms. The examiner added that there was no anatomic/physiologic connection between the service-connected back condition and the headaches and that the onset of the headache condition was at least 15 years after the shoulder condition. The examiner noted that the date in the claims file "clearly" showed that the headaches started after the accidents in the 1990s and that although there were opinions that the headaches were related to a cervical spine condition, there was no evidence linking the headaches to a shoulder condition. A September 2012 VA examination record reflects the Veteran's history of left-sided headaches since 1978. The Veteran explained that the headaches started after he hit his left shoulder and the left side of his face on a door running out of a gas chamber during basic training. He added that he initially had biweekly headaches which ultimately progressed to daily headaches. He denied any other trauma. He reported involvement in a motor vehicle accident in 1998 but denied head injury. After review of the claims file and examination of the Veteran, the examiner determined that the Veteran's headache disorder clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by service. The examiner explained that the Veteran reported a history of frequent or severe headaches at the time of enlistment, that there was no evidence of head trauma or treatment for traumatic headaches during service, and that although the Veteran was seen for non-traumatic headaches, this was the "normal course of the condition" because the Veteran was "already having frequent headaches" prior to enlistment. The examiner added that the headaches were not related to the reported left shoulder injury because the headaches predated service. The Analysis Initially, the Board will consider whether any of the Veteran's headache disorders pre-existed his military service. In this regard, the Veteran reported a history of "severe or frequent headaches" at the history taken at the November 1977 enlistment examination. The record thereafter clarifies that the Veteran was reporting having a problem with frequent headaches which were not associated with nausea or vomiting and which did not cause him to miss work. Moreover, the September 2012 VA examiner opined that a headache disorder clearly and unmistakably existed prior to service. Furthermore, the Veteran and other lay persons have alleged that the claimant had a problem with headaches prior to service. However, the November 1977 examiner did not diagnose the Veteran with any headache disorder. Moreover, the Board finds the contemporaneous findings by the examiner in 1977, who had both an opportunity to examine the claimant and to talk with him about his medical history at that time, more probative than the contrary opinion by the VA examiner in 2012, which was provided thirty-five years after the claimant's entry onto active duty and based on a retrospective review of the appellant's medical history. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). The Veteran in writings and testimony to VA as well as in the history he provided to his VA and private examiners has claimed at times that a headache disorder pre-existed military service. However, the Board finds that diagnosing a chronic headache disorder requires special medical training which he does not have and therefore his opinion as to this question is not probative evidence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Accordingly, the Boards finds' that the most probative evidence of record shows that the Veteran was not diagnosed with a chronic headache disorder prior to military service. Therefore, the Board finds that the record does not contain clear and convincing evidence of a preexisting headache disorder, either migraine or nonmigraine, and the presumption of soundness applies to this claim. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). Given the above, the Board will next turn to the question of whether the Veteran has a current headache disorder due to his military service. See 38 C.F.R. § 3.303. As to the Veteran's migraine headache disorder, the Board finds service connection is warranted based on evidence that a chronic migraine headache disorder began in 1980, during service. The Board has reached this conclusion because service treatment records starting in 1979 documented his complaints and treatment for headaches associated with nausea and severe pain thereafter diagnosed in 1980 as migraine headaches. Moreover, following the Veteran's December 1980 separation from active duty, the post-service medical record starting in September 1981, before his 1995 and 1998 head injuries, document his ongoing complaints and treatment for headaches diagnosed as migraine headaches. While the Board acknowledges that the Veteran sustained post-service head injuries in 1995 and 1998 that appear to have worsened the severity of the migraine headaches he had had since service, as well as caused him to have other types of headaches, the fact remains that his migraine headache disorder started before these post-service injuries. In summary, the Board finds that the evidence, both positive and negative, is at least in equipoise as to whether the Veteran's migraine headache disorder first started while he was on active duty and was a reoccurring problems since that time. Under such circumstances, and granting the Veteran the benefit of any doubt in this matter, the Board concludes that service connection for a migraine headache disorder is warranted. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 3.303 (2012). As to the Veteran's nonmigraine headache disorders, diagnosed as cluster headaches and occipital headaches, the Board finds that service connection is not warranted because the most probative evidence of record shows that they were not present in service and are not related to service. The Board acknowledges that the Veteran complained of nonmigraine headaches in service. However, the Board finds that the most probative evidence of record does not suggest that a nonmigraine headache disorder had its onset in service. Rather the evidence suggests that the in-service complaints were attributed to acute illness, such as respiratory infections, and were not manifestations of a chronic nonmigraine headache disorder. Subsequent service treatment records reflect no histories suggestive of persistent symptoms of a nonmigraine headache disorder, and the initial evidence suggestive of a chronic nonmigraine headache disorder dates more than 15 years after separation, after the injuries in 1995 and 1998. See Maxson v. Gober, 230 F.3rd. 1330, 1333 (Fed. Cir. 2000). Furthermore, the Veteran has not alleged the existence of a nonmigraine headache disorder during service; rather, he has only reported chronic migraine headaches during service. See, e.g., April 2010 hearing transcript. Additionally, the Board finds that the most probative evidence of record does not establish a link between the nonmigraine headache disorders and service. There is no per se evidence of such a link and VA medical professionals have provided multiple opinions that the occipital headaches are due to a non-service connected cervical spine disability. The Board acknowledges that a private chiropractor opined that the documented shoulder injury in basic training was the direct cause of the Veteran's headaches and that the cervical spine disorder, which was caused by service, was a "major component" of the Veteran's headaches. However, the Board does not find this opinion probative evidence of a link between the Veteran's post-service nonmigraine headache disorders and military service because it was provided in conjunction with the claimant's migraine headache disorder. To the extent the opinion can be interpreted to apply to the nonmigraine headaches, however, the Board finds it has no probative value as the chiropractor did not provide an adequate rationale, and it is inconsistent with the medical record, which does not reflect complaints or treatment for the cervical spine or occipital headaches until after the accidents in 1995 and 1998. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (opinion's probative value determined by whether it is supported by a detailed rationale/explanation); Kowalski v. Nicholson, 19 Vet. App. 171 (2005). In contrast, the Board finds the VA medical professionals' determinations that the occipital headaches were due to the cervical spine disorder incurred as the result of injuries in 1995 and 1998 are highly probative as they are consistent with the medical record. Lastly, the Board does not find the private chiropractor's opinion probative evidence because, as noted by the January 2012 VA examiner, this same examiner had earlier provided an opinion to the Social Security Administration in which he opined that the Veteran's headaches were due to his post-service cervical spine/head injuries. The Board also finds that the most probative evidence of record does not establish a link between the nonmigraine headache disorders and a service-connected disability. The record does not include any medical findings of a link between any service-connected disability, to include the right shoulder disability, and the nonmigraine headaches. See 38 C.F.R. § 3.310; Allen, supra. Rather, as discussed above, the evidence indicates that the occipital headaches are due to a cervical spine disorder which is not service connected. The Board acknowledges that the Veteran believes his nonmigraine headaches are due to service. However, the Board finds that the Veteran is not competent to offer an opinion as to etiology of the nonmigraine headaches because such a determination is a question of medical complexity which requires specialized knowledge that the record does not suggest the Veteran has. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). See also Jandreau, 492 F.3d at 1376-77. In summary, the Board finds that the most probative evidence of record only shows that a migraine headache disorder, and no other headache disorder, is related to service, either through date of onset, causation, or as being secondary to a service-connected disability. In reaching the above conclusions, the Board also considered the doctrine of reasonable doubt. 38 U.S.C.A. § 5107(b). However, as the most probative evidence is against the claims, to the extent outlined above, the doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Duty to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 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 the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. With respect to the claim of entitlement to service connection for a migraine headache disorder, the decision above grants service connection for migraine headaches. As such, there is no further need to discuss compliance with the duties to notify and assist. With respect to the claim of entitlement to service connection for a nonmigraine headache disorder, the RO provided the appellant notice by letter dated in July 2005, prior to the initial unfavorable decision by the AOJ in October 2005. Although the notice provided did not address either the rating criteria or effective date provisions that are pertinent to the appellant's claim, such error was harmless because this notice was provided in a July 2010 letter and the matter was subsequently readjudicated. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). Furthermore, the Board finds that even if these letters failed to provide the Veteran with adequate 38 U.S.C.A. § 5103(a) notice, that this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claim after reading the above letters and the rating decision, the statement of the case, the supplemental statements of the case, and the Board remands. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Veteran has been afforded a hearing before an Acting Veterans Law Judge (Acting VLJ) in which he presented oral argument in support of his claims for service connection. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2010) requires that the VLJ who chairs a hearing explain the issues and suggest the submission of evidence that may have been overlooked. Here, during the April 2010 Board hearing, the Veteran was assisted at the hearing by his representative and the representative and the Acting VLJ asked questions to ascertain the extent of any in-service event or injury and whether the Veteran's current headaches are related to his service. They also asked questions to draw out the current state of his disability. No pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or the representative that was not obtained while the appeal was in remand status. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claims, and the Veteran provided testimony pertinent to the claims. As such, the Board finds that no further action pursuant to Bryant is necessary, and the Veteran is not prejudiced by a decision at this time. The duty to assist was also met in this case. The service treatment records are in the claims file. All pertinent available VA and private treatment records and the records associated with the award of benefits from the Social Security Administration (SSA) have been obtained and associated with the file. VA examinations were conducted in January and September 2012. Although an explicit opinion was not obtained with respect to the etiology of the nonmigraine headaches, the Board finds no such opinion was needed because the evidence of record contains sufficient competent medical evidence as to the etiology of the nonmigraine headaches. 38 C.F.R. § 3.159(c)(4). Finally, the Board is satisfied that there has been substantial compliance with the directives issued in the previous Board remands. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The SSA and relevant VA treatment records have been associated with the record and the Veteran has been asked about the location and existence of any outstanding relevant non-VA treatment records. Additionally, a VA examination was conducted in September 2012. The Board acknowledges that the September 2012 VA examination was not conducted by a neurologist, as instructed in the September 2012 VA examination. The examination report is complete, and nothing in the reports suggests that the examiner was not competent to perform the required examination, however. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (holding that VA may satisfy its duty to assist by providing a medical examination conducted by someone who is able to provide "competent medical evidence" under § 3.159(a)(1)). Furthermore, the Veteran has not noted any particular findings (or absence of findings) that were inaccurate or insufficient to suggest that the examination or opinion was inadequate. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). Thus, the Board finds a remand is not required. Compare Stegall v. West, 11 Vet. App. 268 (1998) with Dyment v. West, 13 Vet. App. 141 (1999). ORDER Service connection for a migraine headache disorder is granted. Service connection for a nonmigraine headache disorder is denied. REMAND Service connection was granted for a lumbar spine disability in a January 2013 rating decision. In March 2013, the Veteran submitted a notice of disagreement with the initial disability rating and effective date assigned. Review of the record does not indicate that a Statement of the Case has been prepared as of yet. An unprocessed notice of disagreement must be remanded to the RO for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Thus, these issues must be remanded for issuance of a Statement of the Case. Accordingly, this issue is REMANDED for the following action: Issue a Statement of the Case addressing the claims of entitlement to an earlier effective date for the award of service connection for a lumbar spine disability and increased initial rating for a lumbar spine disability. The Veteran and his representative should be clearly advised of the need, and time limit, within which to file a Substantive Appeal if the Veteran desires to continue his appeal with respect to this matter. Thereafter, an issue is to be returned to the Board only if an adequate and timely substantive appeal is filed The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ NEIL T. WERNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs