Citation Nr: 18145739 Decision Date: 10/30/18 Archive Date: 10/29/18 DOCKET NO. 16-13 988 DATE: October 30, 2018 REMANDED Entitlement to service connection for headaches with blurring of vision is remanded. REASONS FOR REMAND The Veteran had active service from June 1972 to March 1974 and from August 1984 to August 1987. This matter comes before the Board of Veterans Appeals (Board) on appeal from a February 2014 rating decision by the Department of Veterans’ Affairs (VA) Regional Office (RO). The Board sincerely regrets the delay, but this claim must be remanded for further development, as specified below. Such development is necessary to aid the Board in making an informed decision, and will help ensure that the claim is afforded every consideration. 1. Headaches with blurring of vision is remanded. The Veteran asserts that he has a current headache disorder with blurred vision as a result of an in-service head injury. The Veteran’s service treatment records show that in February 1973 he fell and hit his head, resulting in a cut above his left eye, but did not lose consciousness. A neurological examination at that time was within normal limits and no fracture was noted. Closing the wound required sutures. Reserve treatment records show that the Veteran complained of persistent headaches lasting for three days in March 1978, between his two periods of active duty. The assessment is unclear, but the Veteran was prescribed Fiorinal. During the Veteran’s second period of active duty, he complained of photophobia in September 1984 and of headaches (apparently in conjunction with sinusitis) in October 1986. After service, the Veteran underwent a VA examination in February 2014 at which time he gave a history of developing headaches with blurred vision in 1975 “about a year after his concussion, not directly after.” The examiner concluded that it was less likely than not that the Veteran’s headaches were related to his in-service head injury in February 1973. The examiner reasoned that the Veteran’s service treatment records showed that he did not lose consciousness and the Veteran “himself told me [the examiner] the headaches started over a year after an episode where he did lose consciousness, so these make it less likely than not that they were caused by his fall” in February 1973. The VA examiner’s opinion is based upon an inaccurate factual basis, as it appears that he has interpreted the Veteran’s statements to reflect that he suffered a head injury during service in February 1973 with no loss of consciousness, and then a second head injury with loss of consciousness at some point after his March 1974 separation from service with the development of headaches one year later in 1975. However, the Veteran has only reported suffering a single head injury during service in February 1973. As such, remand is required for an additional medical opinion. A VA HCHV Initial Assessment note dated December 26, 2012, shows that the Veteran reported headaches and blurred vision, perhaps dating back to his service in the Marine Corps. Thereafter, in March 2013 there is a notation that the Veteran was treated for a head injury at UCSD in March 2013. See VA Addendum, dated March 22, 2103. On remand, the Veteran’s treatment records from UCSD, as well as his updated VA treatment records, must be obtained. The matter is REMANDED for the following action: 1. Make arrangements to obtain the Veteran’s complete treatment records from the San Diego VA Medical Center, dated from April 2013 forward. 2. Make arrangements to obtain the Veteran’s complete treatment records from UCSD, dated from March 2013 forward. 3. Next, schedule the Veteran for an appropriate VA examination to obtain the following medical opinion. The Veteran’s electronic file must be made available to the examiner for review. All indicated tests and studies are to be performed. A complete rationale should be provided for all opinions given. The examiner should identify all current headache disorders found to be present. (a) The examiner should provide an opinion as to whether it is at least as likely as not (i.e., 50% or greater probability) that any current headache disorder had its clinical onset during service or was caused by the Veteran’s February 1973 head injury. (b) The examiner should provide an opinion as to whether it is at least as likely as not that migraine headaches were manifest within one year of the Veteran’s separation from service, i.e., between March 1974 and March 1975? In providing the requested opinions, the examiner is asked to please consider and address the following: • The service treatment record dated in February 1973 (during the Veteran’s first period of active duty) showing that he suffered a head injury; • Reserve treatment records showing that the Veteran complained of persistent headaches lasting for three days in March 1978 (between his two periods of active duty). The assessment is unclear, but the Veteran was prescribed Fiorinal; and • Service treatment records during the Veteran’s second period of active duty showing that he complained of photophobia in September 1984 and of headaches (apparently in conjunction with sinusitis) in October 1986. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Haas, Associate Counsel