Citation Nr: 18146466 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 14-41 476 DATE: October 31, 2018 REMANDED Entitlement to an initial compensable rating for traumatic headaches is remanded. REASONS FOR REMAND This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an April 2013 rating decision that granted service connection for traumatic headaches and assigned a noncompensable rating. Although the Board sincerely regrets the additional delay, this claim must be remanded for a new VA examination. VA’s duty to assist includes obtaining a medical examination when it is necessary to decide a claim. See 38 U.S.C. § 5103A(d) (2012). Furthermore, when VA undertakes to provide an examination, it must ensure that it is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran was afforded a VA examination in March 2013, at which the Veteran reported constant head pain on the back on this head and sensitivity to sounds. The examiner noted that the Veteran does not experience characteristic prostrating attacks of headache pain. However, in his November 2014 appeal to the Board, the Veteran asserted that he does experience prostrating episodes every month and that he must lie down in a dark room until they go away. He added that he loses some ability to see and he experiences very serious pain. Similarly, at his July 2018 hearing before the Board, the Veteran testified that he experiences prostrating attacks on a daily basis and that the pain is “excruciating.” He said that when he experiences an attack, he “can’t move” and he must lie down in his bedroom and try to relax. He noted that he began meditation to treat his headaches. Based on the foregoing, the Board finds that a remand is warranted for a new examination to fully evaluate the Veteran’s claim and to ensure that the evidence of record reflects the current severity of the Veteran’s condition. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). In addition, the Board notes that, in his November 2014 appeal to the Board, the Veteran indicated that he was seeking a letter from his doctor outlining the nature and severity of his headaches. However, there is no such letter in the file. On remand, the Veteran should be provided an additional opportunity to provide evidence. As for VA treatment records, the claims file does not contain any records later than November 2014. Thus, on remand, updated VA treatment records should be obtained and associated with the claims file. See 38 U.S.C. § 5103A(c); 38 C.F.R. § 3.159(c)(2) (2017); see also Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (holding that documents which are generated by VA agents or employees are in constructive possession of VA and should be obtained and included in the record). The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from November 2014 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for any treatment regarding his traumatic headaches. Make two requests for the authorized records unless it is clear that a second request would be futile. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his traumatic headaches. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the Veteran’s traumatic headaches alone and discuss the effect of that disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Freda J. F. Carmack, Associate Counsel