Citation Nr: 18145773 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-38 333 DATE: October 30, 2018 ORDER Service connection for headaches is granted, subject to the regulations governing the award of monetary benefits. Service connection for obstructive sleep apnea (OSA) is granted, subject to the regulations governing the award of monetary benefits. FINDINGS OF FACT 1. Resolving all doubt in the Veteran’s favor, his headaches are related to active service. 2. Resolving all doubt in the Veteran’s favor, his OSA is related to active service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for headaches are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for entitlement to service connection for OSA are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty from June 1989 to June 1992. 1. Entitlement to service connection for headaches. 2. Entitlement to service connection for OSA, including as secondary to a service-connected disability. The Board concludes that, resolving all doubt in the Veteran’s favor, his headaches and OSA are related to active service. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.310. Service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.30(a) (2017); Walker v. Shinseki, 708 F.3d 1331(Fed. Cir. 2012); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or is legitimately questionable. 38 C.F.R. § 3.303(b) (2018). This alternative means of linking the currently-claimed condition to service is only available if the condition being claimed is one of those specifically identified in 38 C.F.R. § 3.309(a) as chronic, per se. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, entitlement to service connection a secondary basis is warranted when the (1) evidence confirms the Veteran has the claimed disability; (2) there is evidence of a service-connected disability; and (3) the evidence establishes a causation between the service-connected disability and the claimed disability. Depending on the specific condition being claimed, medical evidence is generally, though not always, required to associate the condition being claimed with a service-connected disability. Wallin v. West, 11 Vet. App. 509 (1998); Velez v. West, 11 Vet. App. 148 (1998); and McQueen v. West, 13 Vet. App. 237 (1999). Here, the Veteran believes that his headaches and OSA are directly related to his active duty. Alternatively, he claims that his OSA was caused or aggravated by his service-connected post traumatic stress disorder (PTSD). The Board agrees. In reaching this conclusion, the Board considered the Veteran’s service treatment records (STRs), which were negative for any complaints, symptoms, treatment or diagnosis of a sleep disorder, including OSA. His records, however, indicated that the Veteran sustained a left orbital blowout fracture during a fight. The clinician diagnosed the Veteran with traumatic iritis and comatic retinal. The evidence of record after discharge, reflect that the Veteran has been diagnosed with both OSA and headaches after discharge, which will be discussed in detail below. Regarding the Veteran’s claim for headaches, a May 2015 VA medical opnion reflects that the Veteran did not meet the criteria for a diagnosis of headaches. Instead, the examiner diagnosed the Veteran with sinus headaches. The examiner commented that, based on a review of the claims file, examination of the Veteran and his statements, it was more likely that the Veteran suffered from pressure sensation from sinus congestion or perhaps elevated blood pressure. He stated that there was no known relationship of headaches being caused by or aggravated by the PTSD. As such, the examiner concluded that the Veteran’s disorder, sinus headaches, were not related to active military service. As to OSA, a September 2013 sleep study reflects findings consistent with a diagnosis for OSA. A June 2016 VA examination similarly reflects a diagnosis for OSA. However, the examiner opined that the Veteran’s OSA was not caused by mental health disorder. At the same time, the examiner diagnosed the Veteran with insomnia, which he opined was likely attributed to the Veteran’s service-connected PTSD. The examiner explained that OSA is clearly understood to be secondary to transient, positional, anatomic upper airway obstruction, which, in this case, was aggravated by a recent weight gain of 30 pounds. He further noted that, while there is an increased incidence of a variety of sleep disorders in the PTSD population, including OSA and insomnia, OSA is anatomical and not mental health related according to the medical literature. He further stated that a variety of sleep disorders are common in PTSD patients, but PTSD is incapable of causing anatomical restriction of the upper airway. The examiner, however, did not address whether the Veteran’s PTSD aggravated his OSA. Instead, he concluded that the Veteran’s symptoms were inconsistent with the diagnosis of OSA, and more likely attributable to insomnia. Contrary to these VA medical opinions, the Veteran submitted a private medical opinion dated April 2017, in which, the clinician, Dr. T.K. Guthrie, attributed the Veteran’s headaches and OSA to his active duty. Based on a review of the Veteran’s claims file, he observed that the Veteran’s weight was normal for height in 1988 but his discharge weight was not record as he waived the discharge examination. Dr. Guthrie noted the Veteran’s statement that he had gained over 30 pounds in six months while deployed in Southwest Asia during the Gulf War. He also noted that after deployment, the Veteran was obese enough to be placed on a weight control program. He further observed that the Veteran weighed 261 pounds by 2009 and 299 pounds by 2015. While acknowledging that obesity is the most well-known cause/contributing factor in OSA, he stated that medical research has shown that individuals with PTSD and depression have a predisposition to obesity. In addition, Dr. Guthrie observed that the Veteran had significant depression with his PTSD. Moreover, Dr. Guthrie acknowledged that the obesity is not a service-connectable disorder for VA purposes. He, however, attributed the Veteran’s obesity to his service-connected PTSD, which had its onset in service. As such, he opined that the underlying cause of the Veteran’s OSA was his service-connected PTSD. Dr. Guthrie stated that even aside from the obesity factor, medical research has recently begun to recognize the independent risk of OSA in PTSD patients. He, therefore, opined that the Veteran’s OSA was caused by his service-connected PTSD. Concerning the claim for headaches, Dr. Guthrie observed that the Veteran was treated in September 1991 for an orbital blow-out fracture. He also noticed that the Veteran’s VA optometry examination suggested ongoing interference with work from recurrent photophobic symptoms while the May 2015 VA examiner indicated that the headaches were likely sinus in origin. Dr. Guthrie explained that the orbital blow-out fracture by definition, affect the adjacent sinuses as it is the orbit/sinus interface bone that is usually broken. He further observed that X-rays at the time of the injury showed opacification of the left maxillary sinus. Dr. Guthrie noted that a previous neurology VA examination diagnosed post traumatic headaches attributed to this injury. It also described severe migraine headaches the Veteran experienced two times a month. Dr. Guthrie commented that though migraines are factually blood vessel dilation events in the cerebral locale, the tendency of patients and physicians to describe any severe headaches as “migraine” along with the Veteran’s history of trauma and sinus issues since the sustained orbital blow-out fracture, led him to conclude that the Veteran’s headaches were as likely as not secondary to the September 1991 incident during active military service. The Board acknowledges that there is conflicting medical evidence of record as to the nature and etiology of the Veteran’s headaches and OSA and their relationship to service. Since the Veteran has been diagnosed with headaches and OSA, and the medical evidence of record shows there is a nexus between these disabilities and the Veteran’s active duty and/or service-connected PTSD, the Board finds that the evidence is at least in equipoise as to whether his current headaches and OSA are related to his active service. See 38 C.F.R. §§ 3.303 (a), 3.304(f); Shedden, 381 F.3d at 1166-67. Therefore, resolving all reasonable doubt in the Veteran’s favor, the Board finds that service connection for headaches and OSA is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. (Continued on the next page)   Accordingly, the claims are granted. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Sangster, Counsel