Citation Nr: 1751597 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 99-09 270 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for a headache disability as secondary to hypertension or hypertension medication. REPRESENTATION Appellant represented by: Amanda Christensen, Counsel ATTORNEY FOR THE BOARD A. Parrish, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1986 to August 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a February 1999 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran previously requested a hearing before a member of the Board. In August 2000, however, the appellant withdrew the request for a Board hearing. The Board considers the hearing request withdrawn at this time. See 38 C.F.R. § 20.704(e). The issue of service connection for headaches was previously before the Board in February 2001, July 2010, September 2011, October 2012, May 2013, May 2014, June 2016, and June 2017. In May 2014, the Board denied service connection for a headache disability. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an order dated in February 2015, the Court vacated and remanded the Board's decision for compliance with the instructions in a Joint Motion for a Remand (JMR). The Court order and JMR specifically limited the remand to the issue of whether the Veteran had a headache disability caused or aggravated by hypertension or hypertension medication. See 38 C.F.R. § 3.310. The Court order and JMR did not disturb the portion of the Board's decision denying service connection for a headache disability directly caused by an event, injury, or disease in service under 38 C.F.R. § 3.303. The Board's analysis in this decision is, therefore, limited to whether the Veteran is entitled to service connection for a headache disorder as due to or aggravated by hypertension or hypertension medication. In June 2016, the Board denied service connection for a headache disability as secondary to hypertension or hypertension medication, and the Veteran again appealed to the Court. In November 2016, the Court vacated the Board decision and remanded the Veteran's claim for action consistent with the directives of a JMR. As noted in the Board's June 2016 and June 2017 decisions, the issue of a claim of new and material evidence to reopen the claim for lung damage under 38 U.S.C.A. § 1151 has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is, again, referred to the AOJ for appropriate action. FINDING OF FACT A headache disability was not caused or aggravated by the Veteran's service-connected hypertension or his hypertension medication. CONCLUSION OF LAW The criteria for service connection for a headache disability as due to hypertension or hypertension medication have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 (2017). Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Secondary Service Connection Initially, the Board notes it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to each claim. The Veteran is claiming service connection for a headache disability as due to his service connected hypertension and/or caused by his hypertension medication. Service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). In a February 1999 VA neurological examination, the Veteran stated that he had headaches that occurred with variable frequency, some times more than once a week, but which were usually not disabling. He reported that his headaches might be generalized, but were preferentially on the right side of his head and were often mildly throbbing in nature. The headaches occurred at any time of the day and could last up to two hours, but usually lasted just a brief period of time. The headaches were not preferentially present early in the day, but were scattered irregularly throughout the day. The examiner's impression was that the Veteran had mild, mainly muscle contraction type headaches which may be related to his hypertensive state, but may also be unrelated and with transient paresthesias associated with certain body positions or repetitive movements. In an April 2009 VA examination, the Veteran reported tension headaches which recurred twice a week, with an incapacitating headache every couple of months. The examiner found that the medical records did not support the presence of a significant headache disorder. A September 2010 VA examination report reflects that the Veteran has headaches every other day. He took Tylenol for his headaches and estimated he had 4 incapacitating headaches in the prior 6 months. The examiner stated that the medical records did not support the presence of a significant headache disorder. In a November 2011VA examination, the Veteran was diagnosed with migraines, including migraine variants. He reported suffering constant head pain, pulsating or throbbing head pain, and pain that started in the left temple and moved across the forehead to the right. His non-headache symptoms were reported as nausea, vomiting, and sensitivity to light and sound. He reported that his headaches lasted from 45 minutes to 2 hours, and occurred more frequently than once per month. He reported having very frequent prostrating and prolonged attacks of migraine and non-migraine headache pain. In an October 2012 addendum opinion, the September 2010 examiner stated that hypertension was only considered a primary cause for headache in the circumstance of malignant hypertension, which the Veteran did not have. The examiner stated that the Veteran's hypertension could not be a cause of his headaches. The examiner also stated that headaches were a commonly described potential side effect of almost every drug on the market, thus, while it was possible his headaches could be a side effect of medication (specifically his anti-hypertension medication), there was no evidence to suggest that was likely. Another addendum opinion by the September 2010 examiner was provided in July 2013. The examiner expanded upon his earlier conclusions and stated that hypertension was not a medically recognized cause of headaches in the neurological literature outside the circumstance of malignant hypertension or hypertensive encephalopathy. The examiner further stated that once blood pressure returned to non-malignant levels, the headache resolved. The Veteran did not have chronic malignant hypertension and therefore did not have a hypertension induced headache. An additional addendum in December 2015 addressed whether hypertension or hypertension medication aggravated the Veteran's headache disability. The examiner stated that pain, including headache pain, typically raised blood pressure, but not the other way around, i.e., hypertension was not a cause of pain, including headache pain. The examiner noted that the incidence of hypertension was no higher in the migraine population than the population at large, and, as such, the Veteran's hypertension was not a cause of or aggravating to his migraine disorder. In addition, the examiner stated that while a headache may be a recognized potential side effect of most medications, including the Veteran's antihypertensives, there was no evidence to show that the medications significantly and permanently changed the Veteran's headache disorder. In a July 2017 supplemental opinion, the December 2015 examiner further opined that, "in other words, there is no evidence that his headaches are aggravated (permanently worsened) by his service-connected hypertension [or] treatment thereof." In order to establish service connection on a secondary basis, the evidence of record must establish that the Veteran's headache disorder was either caused by or aggravated by a service-connected disability, in this case his hypertension or hypertensive medication. In this matter, no such finding is warranted. Specifically, the evidence of record establishes that the Veteran's headaches are not related to his hypertension or his hypertension medication. As explained by the VA examiner who provided the reports and opinions in 2011, 2012, 2013, 2015, and 2017, there was no link between hypertension and headaches, except in the circumstance of malignant hypertension or hypertensive encephalopathy, which, as the Veteran did not have those conditions, was not applicable to the Veteran's case. The examiner also stated that typically, pain - including headache pain - caused blood pressure to rise, not the reverse situation and that there was no evidence to show that the Veteran's hypertensive medication significantly and permanently changed the Veteran's headache disorder. Ultimately, the examiner stated that there was no evidence that the Veteran's headaches were caused, aggravated, or permanently worsened by the Veteran's hypertension or hypertensive medication. The Board finds the VA examiner's medical opinions highly probative to the issue of whether the Veteran's headache disorder was related to his hypertension or hypertension medication. The examiner possesses the necessary education, training, and expertise to provide the requested opinion. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The opinions were based on a review of the claims file and an examination of the Veteran. The examiner's review of the Veteran's claims file consists of his service treatment records and post-service medical evidence, and his contentions, upon which the examiner relied upon in giving his opinion. It is clear that the examiner took into consideration all relevant factors in giving his opinions. Significantly, the Veteran has not presented or identified any contrary medical opinion that supports the claim for secondary service connection. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board finds that the only medical opinion evidence of record shows that the Veteran's headache disorder is not related to his hypertension or hypertension medication. The Board has also considered the Veteran's lay statements and does not dispute the reports of his headache symptomology. However, although the Veteran is competent to describe observable symptoms of his headaches, he is not competent to opine as to the etiology of his headache disorder, as he has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, his lay opinions that his headache disorder was caused by his hypertension and/or his hypertension medication do not constitute competent medical evidence and lack probative value. In sum, the claims file does not contain competent and credible evidence that the Veteran's headache disorder is caused or aggravated by his hypertension or his hypertension medication. Accordingly, as the preponderance of the evidence is against the claim for service connection, the benefit-of-the-doubt rule is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for headaches as secondary to hypertension or hypertension medication is denied. ____________________________________________ Lesley A. Rein Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs