Citation Nr: 18148729
Decision Date: 11/08/18	Archive Date: 11/07/18

DOCKET NO. 16-58 265
DATE:	November 8, 2018
REMANDED
Entitlement to an initial compensable rating for tension headaches is remanded.
REASONS FOR REMAND
The Veteran had active service from July 1988 to August 1988. 
Entitlement to an initial compensable rating for tension headaches is remanded.
The Veteran asserts that his headache disability is worse than reflected in the July 2016 VA examination.  In his September 2016 notice of disagreement, he reported that when he has migraine headaches he stays in bed for 3-4 days and that he needs to be in the dark to avoid noise and smells.  These reported symptoms are worse than those reported during the July 2016 VA examination.  The July 2016 VA examination report reflects that the Veteran has headache symptoms that last less than one day and that he did not have prostrating attacks.  The Veteran should be provided a more contemporaneous VA examination to ensure that the record includes sufficient medical evidence to properly evaluate the disability under consideration.  See 38 C.F.R. § 5103A; 38 C.F.R. § 3.159; Snuffer v. Gober, 10 Vet. App. 400, 403 (1997).  See also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide a veteran with a thorough and contemporaneous medical examination).
While on remand, the Veteran should be offered another opportunity to identify any VA or private medical treatment that he receives for his headache disability. 
The matter is REMANDED for the following action:
1. Offer the Veteran the opportunity to identify any outstanding VA and/or private treatment records, and offer him the opportunity to submit the appropriate authorization and consent form so that VA may obtain any outstanding private records on his behalf.  If the Veteran completes the appropriate authorization, make two attempts to seek the records unless it is futile to make more than one attempt. 
2. Following receipt of any treatment records, afford the Veteran an examination by an appropriate clinician to determine the current severity of his service-connected headache disability.  The examiner must review the electronic file, including the Veteran’s symptoms reported in the September 2016 notice of disagreement.  
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.  To the extent possible, the examiner should identify any symptoms and functional impairments due to the headache disability alone and discuss the effect of the Veteran’s headache disability on any occupational functioning and activities of daily living.  
3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, readjudicate the Veteran’s claim based on the entirety of the evidence.  If the claim remains denied, issue the Veteran a supplemental statement of the case.  Allow an appropriate period of time for response.  


 
 
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Donna D. Ebaugh, Counsel