Citation Nr: 1800909 Decision Date: 01/08/18 Archive Date: 01/19/18 DOCKET NO. 10-36 485A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for headaches, to include as secondary to posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Kenneth M. Carpenter, Attorney at Law ATTORNEY FOR THE BOARD A. Rocktashel, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1966 to October 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. A September 2009 rating decision denied entitlement to service connection for headaches. In February 2014, the Board remanded this matter for further evidentiary development. The requested development was completed, and the case has now been returned to the Board for further appellate action. FINDING OF FACT PTSD caused the Veteran's headache disorder. CONCLUSION OF LAW Disability due to headaches is proximately due to or the result of service-connected PTSD. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran contends that service connection is warranted for a headache disability, either directly or as a result of his service-connected PTSD. In numerous statements made throughout the claims file, the Veteran reports that ever since returning from Vietnam, he had neck and head pain whenever he felt "stressed" or had negative thoughts. He has not made specific contentions regarding any in-service injury to his neck resulting in an orthopedic neck disability. The Veteran has been denied service connection for a pinched nerve in the lower back and neck and arthritis or spondylosis of the cervical spine. See October 2002 rating decision and February 2014 Board Decision, respectively. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Except as provided in 38 C.F.R. § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b). In this case, service treatment records are silent for complaints, findings, or diagnoses of headaches. In a September 1969 separation report of medical history, the Veteran did not identify having any headache problems, and the only "illness or injury other than those already noted," which included mumps, that he identified was "chicken pox, measles." On separation examination in September 1969, clinical evaluation of the neurologic system was reported as normal. The Veteran's service personnel records reflect that he served in the Republic of Vietnam from December 1967 to December 1968. His DD Form 214 (Report of Discharge) lists his military occupational specialty as Rad[io] [Teletype] Operator. Awards and medals were not indicative of participation in combat with the enemy. As a result, the "combat presumption" is not applicable to the Veteran's claim. 38 U.S.C. § 1154(b) (2012); 38 C.F.R. § 3.304(d) (2017). Private chiropractic records from J. J, D.C., are of record. A June 1993 treatment note lists the Veteran's current complaint as pain in the left side of his neck and described the pain as starting in the left side of the neck and head and coming over the top of the left eye. The note reports that "lifting [weights] and sex" gives him this pain and that "[six] years ago [in 1987] this happened." The Veteran stated that he woke with the pain the previous Saturday and it occurred again. The Veteran clarified in a handwritten note that lifting weights and sex were not the only times this head pain occurred. Treatment records dated from January 1999 to October 2003 from Heartland Regional Medical Center and from March 1999 to February 2007 from the Veteran's private primary care physician, J. D., M.D., were silent for complaints, findings, or diagnoses of headaches. Treatment records from D. P., D.C., for 2002 reflect the Veteran's complaint of neck and back pain. Headaches were not reported. A March 2003 treatment record from J. J., D.C., indicates that the Veteran reported having the flu and straining his neck one year previously [in 2002] and seeing [Dr.] P[]. Subsequent treatment records dated from March 2003 to August 2005 reflect chiropractic treatments for neck pain and the Veteran's reports of having headaches in August 2005. The Veteran was afforded a VA general medical examination in September 2005 in connection with his June 2005 claim for nonservice-connected pension. He reported that "when someone has done him wrong and he thinks about" it, neck pain lasts all day and "goes up into a headache." No diagnosis of a headache disorder was either made or ruled out as a result of this examination. The Veteran established VA medical care in November 2005. During a May 2006 VA primary care visit, he reported struggling with anxiety, stress, and depression for the past five years and that his "biggest problem is that the stress creates a pain in his neck and leads to occasionally disabling headaches." The assessment was anxiety disorder with somatoform manifestations. During a June 2006 primary care follow-up visit, he reported that headaches have lessened a bit. The assessment was PTSD with somatoform manifestations. A behavioral health consultation order was submitted. During a June 2006 VA psychiatry consultation, the Veteran described "a physical manifestation of his anxiety in which his neck becomes tight and painful, then progress[es] to tension headaches, all of which may last for [two to three] days." In five lay statements received in September 2008, and which were dated in December 2006 and January 2007, the Veteran's ex-wife and four former work colleagues described their observations of the Veteran experiencing head and neck pain or migraines. Each person related that the Veteran had sought medical help and was told that his head and neck pain was related to stress. The Veteran's ex-wife related that after the Veteran returned from Vietnam, he was sent to Puerto Rico for war games, and he returned from Puerto Rico "with severe headaches and migraines and complained a lot and seemed very nervous." The Board finds this statement particularly credible in its level of detail and the personal knowledge of the Veteran's ex-wife through observation when he returned from service. An August 2008 VA treatment record reported the Veteran described what sounded like a tension headache. In correspondence received by VA in September 2008, the Veteran stated that after leaving Vietnam, he had violent nightmares and neck and head pain when stressed. A March 2009 letter opinion from the Veteran's VA treating psychologist, Dr. P.T., states that since the time she first met the Veteran (July 2006), he complained of neck and head pain related to stress. Dr. P.T. recounts that although the Veteran has seen many medical doctors and chiropractors, no medication or other treatment has been effective in treating this disorder. Dr. P.T. opined that the Veteran's neck/head pain syndrome is secondary to his vulnerability to stress in the form of PTSD. In a February 2010 letter, the Veteran's treating VA psychologist opined that the Veteran's PTSD exacerbates his chronic neck and headache pain. In contrast, a February 2010 letter from a private physician, S. M., M.D., indicated that the Veteran was having significant problems with his eyelids drooping into his vision and believed that the problem caused visually significant eye strain and headaches. Dr. M. related that the Veteran underwent a bilateral upper lid blepharoplasty in December 2009 and was doing well at his initial follow-up visit. No follow-up as to the efficacy as to reducing headaches was made. It appears that this did not reduce the Veteran's headaches as revealed by a January 2010 VA crisis intervention note, which showed the Veteran reporting intolerable pain in the neck and head. A January 2010 physical medicine rehabilitation consultation note revealed treatment for a 40 year history of headaches. Upon a May 2016 VA headaches examination, the diagnosis was a headache disorder radiating from neck pain. The examiner reported that the Veteran looked lost and overwhelmed at the examination. He had some difficulty hearing and some slowness in understanding. He was keen to provide history. His estimated intelligence was only average (or below). There were neither delusions nor hallucinations. There were cognitive deficits in a brief examination, and the Veteran was oriented and alert. The examiner reported that the Veteran described a 20 foot fall from a ladder in 2012 in which he fractured vertebrae, and he suffered back and neck pain. The examiner stated that the Veteran did not bring up headaches at any time during the interview until the examiner told the Veteran that the purpose of the examination was to assess his headaches. Reportedly, the Veteran, as an afterthought and with much prompting, provided a vague, unreliable and indistinct description of headaches. After the evaluation, the examiner opined that the headache disorder described is less likely than not (less than 50 percent probability) incurred in or caused by any service injury, event or illness. The examiner reasoned that headaches had their onset after a fall from a ladder in 2012 in which he suffered vertebral fractures. The examiner also opined that the headache disorder is less likely than not proximately due to or the result of the Veteran's service-connected PTSD. The examiner's rationale was that the headaches had their onset after a fall from a ladder in 2012, in which the Veteran suffered vertebral fractures. In a February 2017 clarification opinion, the examiner stated that there are references to headaches and allusions to tension and stress in occasional notes between 2005 and 2010. However, during this same period, the Veteran had a long and comprehensive problem list including many complaints and conditions. The examiner reasoned that headaches never found a place on any problem list. During this same period the Veteran was seen more than once by two separate neurologists, and neither neurologist diagnosed headaches. Therefore, the examiner opined that, even though there are mentions of headaches prior to 2012, at no time do they find a place in the problem list and two neurologists were not convinced enough to mention them in their diagnosis. The examiner further reasoned that he was unable to find neither a clear headache disorder nor any connection to PTSD. With an opinion not supporting PTSD as the cause for any headache in this case, the examiner also opined that headaches, if any, were not worsened by PTSD. The rationale was that the problem lists, often running into 37 items, by different providers did not include headaches, and that on examination, the Veteran offered no spontaneous complaint of headaches. The examiner was not impressed by headaches as a topic nor with any connection of headaches to PTSD in the Veteran. Based on a review of the record, the Board finds that service connection for headaches as due to PTSD is warranted. In that regard, the March 2009 and February 2010 opinions from the Veteran's treating psychologist provide medical evidence of the relationship between stress in the form of PTSD and headaches. The opinions are highly probative as they are from the Veteran's treating provider, who had significant knowledge of the Veteran's treatment and symptoms. Further support of the Veteran's claim are May 2006 and June 2006 VA treatment records showing assessments of anxiety and PTSD with "somatoform manifestations." In other words, the Veteran's psychiatric disorder caused unexplained physical symptoms. Thus, there are multiple medical sources showing that the Veteran's "head pain" is secondary to his vulnerability to stress in the form of PTSD. The Board rejects the May 2016 VA medical opinion and the February 2017 clarifying opinion because they appear to be based on an inaccurate view of the record. The VA medical examiner relied heavily on a lack of headaches noted in the VA problem lists. However, the Board notes VA treatment records show the Veteran reporting headaches in April 2013, stress headaches in May 2014, and headaches in general in March 2015. Thus, although headaches may not be shown on the problem lists, the Veteran did consistently report having them. Therefore, the Board finds the VA examiner's opinions to carry significantly less probative weight than the treating provider's opinion. As the preponderance of the evidence shows the Veteran has a current headache disorder that is secondary to PTSD, service connection is warranted. Reasonable doubt has been resolved in the Veteran's favor. ORDER Service connection for headaches as secondary to PTSD is granted. ____________________________________________ D. Martz Ames Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs