Citation Nr: 1328677 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 11-13 041 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to service connection for a chronic headache disorder. REPRESENTATION Appellant represented by: Kentucky Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from August 1991 to December 1995. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In October 2011, the Veteran testified at a Board video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims folder. At the hearing the Veteran submitted additional evidence and waived the right to have the RO initially consider it. 38 C.F.R. §§ 20.800, 20.1304 (2012). As a final preliminary matter, the Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with this appeal. 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. FINDINGS OF FACT The evidence of record is in equipoise as to whether the Veteran's current headache disorder had its onset in active service. CONCLUSION OF LAW The criteria for service connection for a chronic headache disorder have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Given the Board's favorable disposition to grant the claim for service connection for a headache disorder, the Board finds that no discussion of VCAA compliance is necessary at this time. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease 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 Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant 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 claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran asserts that she developed a chronic headache disorder in service, to include as due to head trauma. In statements and at a hearing in October 2011, she reported onset of recurrent headaches after she struck her head on a trailer. The headaches continued intermittently throughout the years increasing in severity and frequency as time progressed, until over-the-counter medication was no longer effective and she sought medical treatment. A Veteran is competent to testify to factual matters of which she had first-hand knowledge. Lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the personal knowledge of the witness. Here the Board finds that the Veteran is credible and competent to report that she had headaches in service. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Significantly, her reports of headaches in service are corroborated by the service treatment records, which documented complaints of headaches. The service treatment records show that in November 1992 the Veteran was seen for complaints of headaches. She was treated with Motrin. The clinician noted an assessment of tension headaches versus migraine. She was seen again in April 1993 after she struck her head on a trailer. The Veteran reported dizziness but denied loss of consciousness. She had pain on the left side of her head and there was a knot over the left eye. The clinician noted edema, pain on palpation and reactive to light and accommodation (PERRLA), along with an assessment of possible concussion. While the service treatment records do not document additional treatment for headaches, the Veteran testified in October 2011 that she continued to experience headaches on a monthly basis in service, however, she did not seek additional medical treatment as she was able to effectively treat the headaches with over-the-counter medication, which essentially was the same treatment she received in sick bay. Reportedly, she continued to successfully treat ongoing headaches with over-the-counter medication for many years after discharge from service. The Board also finds her reports ongoing recurrent headaches since service to be credible. See Layno v. Brown, 6 Vet. App. at 470 (1994). Lay evidence concerning recurrence of symptoms after service, if credible, can be competent, despite the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). After service, VA treatment records starting in September 2004 noted complaints of chronic headaches. In December 2010 a clinician recorded a history of headaches after a head injury during service. Reportedly, she treated the headaches with medication since service with diminishing relief. The assessment was posttraumatic versus migraine headaches. She was prescribed medication to treat the headaches. The Veteran underwent a VA neurological examination in January 2011. She reported onset of headaches in approximately 1993 after a head injury. She described headaches that increased in frequency and intensity throughout the years. At the time of the examination, she described weekly headaches that localized frontally and on the face causing her eyes to water. Half of the attacks were characterized as prostrating. Initially, the Veteran had been prescribed medication with little results, but was now using a different prescription medication with good response. Reportedly she had been told the headaches could be migraines or cluster headaches. Following an examination of the Veteran the examiner diagnosed headaches and opined that he could not render an opinion regarding the etiology of the headaches without resorting to speculation. The VA examiner's opinion neither supports nor weighs against the Veteran's claim. In support of her claim, in December 2010 the Veteran submitted witness statement from her relatives, to include her son and sister, who essentially reported witnessing the Veteran suffering from chronic recurrent headaches for at least 10 to 15 years. They described how the Veteran's behavior would change with onset of headaches. The Veteran appeared at times weakened by the headaches and unable to function normally during these episodes. It was noted that over-the-counter medication appeared to be ineffective in treating the Veteran's headaches. The Board considers the Veteran's statements regarding the onset of headaches in service and the recurrence of symptomatology since service to be credible as they are facially plausible, internally consistent, and consistent with the other evidence of record, to include medical history recorded in the service and post-service VA treatment records. Caluza v. Brown, 7 Vet. App. 498 (1995). After considering all the evidence and resolving reasonable doubt in the Veteran's favor, the Board finds that the competent and credible evidence is in equipoise as to whether the Veteran's chronic headache disorder had its onset during her period of service. Therefore, affording the Veteran the benefit of the doubt, the Board finds that service connection for a chronic headache disorder is warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a chronic headache disorder is granted. ____________________________________________ K.A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs