Citation Nr: 1805583 Decision Date: 01/29/18 Archive Date: 02/07/18 DOCKET NO. 14-21 171 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for headaches. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD P. Childers, Counsel INTRODUCTION The Veteran's military service includes a period of active duty for training/basic training from December 5, 2011 to December 15, 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in January 2014 by a Department of Veterans Affairs (VA) Regional Office (RO); which denied, in pertinent part, service connection for migraine headaches. In August 2017, the Veteran testified by videoconference before the undersigned Veterans Law Judge. During that hearing the Veteran requested a 60 day extension within which to submit a medical opinion; which the undersigned granted. In September 2017, the Veteran submitted the opinion. The Board notes that relevant evidence has been associated with the claims file since the May 2014 statement of the case and there has been no supplemental statement of the case; however, in view of the fully favorable disposition of this claim for service connection, remand for review of this evidence by the agency of original jurisdiction is not needed. FINDING OF FACT The Veteran's headaches are related to an injury that occurred during the Veteran's basic training. CONCLUSION OF LAW The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran seeks service connection for headaches, which he says are related to an injury during basic training. See August 2017 Board Hearing Transcript, p. 3. He specifically testified that on emerging from a shower while in basic training he fell onto his back, hit his head, and was rushed to the emergency room (Transcript, p. 3); and that "throughout that time, I complained about having headaches." Transcript, p. 4. General Legal Criteria 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. § 1110; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Facts and Analysis Service treatment records (STRs) confirm that on December 8, 2011 the Veteran slipped and fell onto his back while stepping out of a shower during basic training and was transported to the base emergency room for treatment for obvious injury to the low back and right ankle. CT scan of the brain at that time was negative, but the Board notes that the CT scan order included the comments "with fall acting confused." See STRs dated in December 7, 2011. This is probative evidence in support of the Veteran's claim that he hit head during the fall. The mere fact that a CT scan was ordered indicates that the Veteran may indeed have hit his head during the fall as he contends. Thereafter, the Veteran began to have headaches. See Board Hearing Transcript, pp. 3-4. See also VA and private medical records dating from 2013. There is no medical evidence of headaches, prior to the December 2011 incident. See military examination reports dated in October and November of 2010. The Veteran is service connected for low back and right ankle disabilities related to the same December 2011 incident. On VA examination in December 2013, the examiner (a physician's assistant) gave the opinion that the Veteran's headaches were not related to service because the CT scan during service was normal. This is probative evidence against the claim. On the other hand, a private physician has opined that, based on the Veteran's medical records, it is more likely than not that the Veteran's headaches are related to the fall he sustained in 2011 because "this was his first complaints with continuous headaches." See August 2017 opinion from private physician. This favors the claim. The Board accordingly finds that there is an approximate balance of positive and negative evidence for and against the claim regarding the nexus element. When reasonable doubt is resolved in the Veteran's favor, the Board finds that his headaches are related to an injury that occurred during the Veteran's basic training. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service connection for headaches is accordingly warranted. ORDER Service connection for headaches is granted. ____________________________________________ RYAN T. KESSEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs