Citation Nr: 18151183 Decision Date: 11/20/18 Archive Date: 11/16/18 DOCKET NO. 99-09 270 DATE: November 20, 2018 REMANDED Entitlement to service connection for a headache disability as secondary to hypertension or hypertension medication is remanded. REASONS FOR REMAND The Veteran had active service from January 1986 to August 1994. This matter comes before the Board of Veterans’ Appeals (Board) from a February 1999 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied service connection for headaches. In a May 2014 decision, the Board denied service connection for headaches. The Veteran appealed the decision to the U.S. Court of Appeals for Veterans Claims (Court). In February 2015, the Court granted a Joint Motion for Remand (JMR), vacated the Board’s May 2014 decision, and remanded the matter for readjudication. Both the Court’s order and the JMR limited the remand to the issue of whether the Veteran had a headache disability caused or aggravated by his service-connected hypertension or medication prescribed to treat that disability. The Court order and the JMR did not disturb the portion of the Board’s decision denying service connection for a headache disability on a direct basis. In a June 2016 decision, the Board denied service connection for a headache disability as secondary to hypertension or hypertension medication and the Veteran again appealed to the Court. In November 2016, the Court again granted a JMR, vacated the Board’s June 2016 decision, and remanded the matter for readjudication. In a November 2017 decision, the Board again denied service connection for a headache disability as secondary to hypertension or hypertension medication and the Veteran again appealed to the Court. In June 2018, the Court again granted a JMR, vacated the Board’s November 2017 decision, and remanded the matter for readjudication. 1. Entitlement to service connection for a headache disability as secondary to hypertension or hypertension (HTN) medication is remanded. In the June 2018 JMR, the parties agreed that a July 2017 VA medical opinion was inadequate. The parties described the opinion as “internally inconsistent” and agreed that it “provided a woefully inadequate rationale.” The parties noted that Specifically, the examiner stated, first, that “There is no apparent relationship between his medications used to treat his HTN and his documented headache complaints in the medical records.” Then, the examiner appears to begin the next sentence with the opposite: “Thus, while headache may be a recognized potential side effect of most medications including his antihypertensives....” However, this is not sufficient, because the examiner then concludes in that very same sentence that: “... there is no evidence to show that his medications have significantly and permanently changed his [headache] disorder.” The examiner gives no rationale whatsoever for this series of internally-inconsistent, or at least internally-confounding, sentences. Either it is at least as likely as not that Appellant’s HTN medications cause or aggravate his claimed headaches, or it is not. If it is less likely than not that Appellant’s HTN medications cause or aggravate his claimed headaches, the examiner must explain why, and in so doing provide a rationale that informs the Board of a medical expert’s judgment on a medical question and the essential rationale for that opinion. Nothing less will suffice. Appellant must be provided with an adequate opinion, and remand is unfortunately necessary for the fourth time. The matter is REMANDED for the following action: Obtain an opinion from a clinician as to whether it is at least as likely as not that the Veteran has a headache disability which is causally related to or aggravated by his service-connected hypertension or medication used to treat that disability. The clinician must provide a rationale to support any conclusion reached. The clinician is asked to provide answers to the following questions: Is it at least as likely as not (50 percent or greater likelihood) that the Veteran’s headache disability is causally related to his service-connected hypertension or medication used to treat that disability? If not, is it at least as likely as not (50 percent or greater likelihood) that the Veteran’s headache disability has been aggravated by his service-connected hypertension or medication used to treat that disability? Aggravation in this context means “any increase in disability.” If aggravation is found, the examiner should provide a baseline level of severity of the headache disability prior to aggravation and the level of additional disability which is considered proximately due to the service-connected hypertension. This may be ascertained by the medical evidence as well as any lay statements as to the severity of the headache disability over time. Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Yun, Associate Counsel