Citation Nr: 18153631 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 08-30 119 DATE: November 28, 2018 REMANDED Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran had active military service from July 1972 to June 1973. This matter originally came before the Board of Veterans’ Appeals (Board) from a January 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This case has a long procedural history. In a July 2014 decision, the Board denied the Veteran’s claim for service connection for headaches. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court), resulting in a December 2015 Order remanding the claim for readjudication in compliance with the Memorandum Decision, to the extent that it found that the July 2014 Board decision failed to provide an adequate statement of reasons or bases for relying on an August 2012 addendum opinion. In May 2016, the Board remanded the Veteran’s claim for further development consistent with the December 2015 Memorandum Decision. In a March 2017 decision, the Board denied the Veteran’s claim for entitlement to service connection headaches. The Veteran subsequently filed a timely appeal with the Court which vacated the Board’s March 2017 denial in an April 2018 order, remanding the decision for further proceedings. Entitlement to service connection for headaches is remanded. The Veteran maintains that he is entitled to service connection for his headaches. In vacating the Board’s March 2017 decision, the April 2018 Memorandum Decision identified deficiencies in the August 2016 VA examination and instructed that the Board must ensure compliance with its previous remand directives in order to adjudicate the Veteran’s claim. Specifically, the April 2018 Memorandum Decision found that the August 2016 opinion did not substantially comply with the Board’s May 2016 remand directives in that the examiner failed to address the very reason for obtaining the examination in the first place: namely, to address the Veteran's lay statements regarding his headache symptoms in service and continuity of symptoms since service. The April 2018 Memorandum Decision noted that it was unclear why the Board determined that it could decide the appeal after obtaining an inadequate opinion since it had previously found that a specific expert opinion was required. It further found that the lack of clarity is as a result of the March 2017 decision which concluded that there had been substantial compliance with the Board’s prior remands, but offered no further details or analysis. Specifically, the August 2016 VA medical opinion’s supporting rationale focused almost entirely on the objective evidence of symptoms at discharge and following service. The examiner stated that the medical opinion was based on a review of the available medical records, however in condensing the Veteran's report that his migraines began in the 2000s, the examiner did not address the Veteran's complete description of headaches that began during basic training, continued and worsened over the years, eventually culminating in a diagnosis of migraines in the 2000s. The Veteran’s reported history was almost entirely absent from the medical opinion given by the August 2016 examiner according to the April 2018 Memorandum Decision. The April 2018 Memorandum Decision instructs the Board to ensure compliance with its remand directives, specifically, the purpose of the May 2016 Board remand which was to obtain a medical opinion that addressed the appellant's lay statements regarding his headache symptoms in service and his reported continuity of symptoms since service. Therefore, further addendum opinion is required. The matter is REMANDED for the following action: 1. Obtain any outstanding VA treatment records identified by the Veteran. Also, make reasonable requests for any non-VA records for which the Veteran provides sufficient identifying information and the necessary release form. If any records cannot be obtained after appropriate attempts, notify the Veteran of the attempts and outcomes, and allow an opportunity to provide the missing records. 2. After the receipt of any such outstanding treatment records, return the claims file to the August 2016 VA examiner, if available, or to an appropriate medical professional. The need for a physical examination or interview is left to the discretion of the medical professional offering the opinion. The examiner should provide the following opinion: Is it at least as likely as not (50 percent or greater probability) that any diagnosed headache condition is related to the Veteran’s active service? The examiner must address the service medical records and lay statements. Additionally, the examiner should consider any conflicting medical opinion. A rationale for the opinion should be provided. Additionally, the examiner must consider the Veteran's statements regarding onset of symptoms during service and continuity of symptomatology after service. KRISTY L. ZADORA Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD O. Owolabi, Law Clerk