Citation Nr: 1809043 Decision Date: 02/12/18 Archive Date: 02/23/18 DOCKET NO. 10-49 089 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for sleep apnea, to include as a due to exposure to environmental hazards during Gulf War service or as secondary to a service-connected disability. 2. Entitlement to service connection for headaches, to include as a due to exposure to environmental hazards during Gulf War service or as secondary to a service-connected disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Setter, Associate Counsel INTRODUCTION The Veteran served on active duty for training from May 1988 to September 1988 and on active duty from October 1990 to May 1991, with service in Southwest Asia from November 1991 to April 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The case is currently under the jurisdiction of the RO in Atlanta, Georgia. The Board remanded the issues on appeal for additional development in August 2015 and March 2017. The directives having been substantially complied with, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). After the September 2017 Supplemental Statement of the Case (SSOC) was issued, new medical evidence was added to the Veteran's claims file in November and December 2017. Per 38 C.F.R. § 20.1304(c), if pertinent evidence has been received and associated with the record, then it must be referred to the Agency of Original Jurisdiction (AOJ) for review, unless this procedural right is waived by the appellant or his representative. The paragraph states "[e]vidence is not pertinent if it does not relate to or have a bearing on the appellate issue or issues." Id. The Veteran signed a waiver in September 2017, but additional medical evidence was added after that date. The Board, however, has determined that this new medical evidence is not material to this appeal, and thus finds that either an additional SSOC or a waiver of AOJ review is not necessary. See 38 C.F.R. § 19.37. See Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). The Veteran requested a hearing before the Board in his December 2010 VA Form 9. However, in a subsequent communication received in December 2014, he withdrew his request for a hearing. 38 C.F.R. § 20.704(e). FINDINGS OF FACT 1. A sleep apnea disability was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 2. A sleep apnea disability is not caused or aggravated by a service-connected disability. 3. A headache disability was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 4. A headache disability is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a sleep apnea disability are not met. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.310, 3.317 (2017). 2. The criteria for service connection for a headache disability are not met. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.310, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Where VA makes reasonable efforts to obtain relevant non-Federal records, but is unable to obtain them, or after continued efforts to obtain Federal records concludes that it is reasonably certain they do not exist or that further efforts to obtain them would be futile, VA will provide the claimant with either oral or written notice of that fact. See 38 C.F.R. § 3.159(e); Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1349 (Fed. Cir. 2003). Parts of the Veteran's service treatment records could not be located and were deemed unavailable, and VA has issued a memorandum of unavailability for the claims file and notifying the Veteran, dated June 14, 2010. In sum, the Board is satisfied that the originating agency properly processed the Veteran's claims after providing the required notice and that any procedural errors in the development and consideration of the claims by the originating agency were insignificant and non-prejudicial to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection for Sleep Apnea and Headache Disabilities A. Legal Criteria for Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (2017); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Finally, for veterans who served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established for chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or for a medically unexplained multisymptom illness (e.g., chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome). See 38 C.F.R. § 3.317. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (West 2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2017). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran asserts his claimed sleep apnea and headaches are the result of his service in Southwest Asia in 1991. The Veteran has also claimed that these disabilities are secondary to service-connected disability. The Veteran is currently service connected for post-traumatic stress disorder (PTSD), degenerative joint disease of the right knee, and a left leg injury with residuals. B. Evidence and Analysis -Sleep Apnea The Veteran's available service treatment records are silent for any mention of sleep apnea. The Veteran received his initial diagnosis of sleep apnea in December 2008 after a sleep study was accomplished, in response to his initial complaint with VA in September 2007. The Veteran received a VA compensation and pension examination in August 2010. Here, the examiner noted the Veteran having sleep disturbances which he reported beginning in service, but without a specific date. The Veteran cited his chronic headaches as being associated with the sleep difficulty, and noted the December 2008 sleep study which diagnosed moderate sleep apnea at that time. He indicated he did not seek treatment during service, but now experienced intermittent frontal headaches two to three times per week that would last 10 to 15 minutes. He also reported being restless in his sleep and excessive snoring. In an opinion for direct service connection, the examiner opined it was less likely than not the Veteran's sleep apnea was related to service because of the gap of time between his Gulf service in early 1991 and his first complaint of a sleep disturbance in September 2007. This examiner also opined that the headaches noted were secondary to the sleep apnea. The Veteran received another VA examination in July 2016. This examiner noted a diagnosis of sleep apnea, originally made in 2008 after a sleep study was performed. The examiner noted the Veteran used a continuous positive airway pressure (CPAP) machine daily. The Veteran asserted that his sleep apnea had begun in 1990 while he was stationed in southwest Asia for the 1990-91 Gulf War. He reported experiencing sleep problems during the Gulf war and that he would "jump up" in his sleep. The examiner noted current symptoms of headache and difficulty sleeping with PTSD. An opinion was not provided for direct service connection for sleep apnea. The Veteran received a VA examination in September 2016. The examiner noted that while the Veteran complained of snoring, that his snoring was a distinct and separate diagnosis from sleep apnea, pointing out that sleep apnea cannot be self-diagnosed, but only by a sleep study. This examiner opined that it was less likely than (less than 50 percent probability) that the Veteran's sleep apnea is related to his active military service. His rationale was that service records contain no indication of complaints of sleep apnea nor any ongoing treatment. With regard to secondary service connection, this examiner also indicated that the Veteran's sleep apnea was unlikely to be related to the Veteran's service-connected PTSD because the latter is a mental condition based on stress, and does not of itself cause an obstruction to the outflow of air during sleep. This examiner pointed out that the peer-reviewed literature shows that while PTSD and sleep apnea may co-exist as co-morbidities, the studies do not show that PTSD causes sleep apnea. The examiner concluded that the medical records do not indicate that the Veteran's PTSD has aggravated the sleep apnea beyond its normal progression, because mental conditions do not cause an obstruction to the outflow of air during sleep. The examiner provided an addendum opinion from VA in June 2017. Based on a review of the entire claims file, this examiner opined for direct service connection that the claimed sleep apnea was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale was that the sleep apnea did not have an onset or manifestation during active service, and was not specifically caused by, even with a delayed onset, by any event or exposure or activity during his time of active service. The examiner noted the initial diagnosis of sleep apnea occurred in 2008, more than 15 years after his Gulf War service in 1991. The examiner noted the possible effects of burn pits or burning oil wells, as cited by the Veteran, but noted none of the medical research would indicate a causal effect on the development of sleep apnea. The examiner noted the pathophysiological causes of sleep apnea, such as obesity, a narrowed airway, increased neck circumference, frequent nasal congestion, and others all contribute to sleep apnea, and noted also the Veteran's medical history indicating these factors. With regard to secondary service connection, the examiner opined that the Veteran's sleep apnea is not secondarily related to some other condition or incident or service-connected entity, including his service-connected knee trauma and PTSD. His rationale was that there is no medical evidence to establish a causal relationship and the other explanations for sleep apnea and the multitude of other causative or contributing factors are legion and provide a more likely reasoning for the causative effect. The examiner noted that sleep apnea and PTSD can be co-morbidities, but also that because both conditions exist doesn't mean one caused the other. The examiner noted a review of the medical literature indicates to date that no study exists which shows that PTSD triggers sleep disorders. Therefore, per the examiner, the Veteran's sleep apnea is less likely than not to have a secondary service connection to any service-connected condition which the Veteran has, including his PTSD. Continuing, for the same reasoning, this examiner did not find a likely justification to warrant an "aggravating service connection" because it is felt to be less likely than not that the Veteran's non-service connected sleep apnea was aggravated beyond its normal progression or beyond its natural course by any of the veteran's service-connected conditions. This June 2017 examiner also opined that the Veteran suffers from sleep apnea which is a "diagnosable condition" and is not felt to be a part of any particular syndrome or constellation of a multitude of unexplained symptoms related to Gulf War or Southeast Asia or burn pit exposures. Thus, this condition is felt to be less likely than not to represent a Gulf War syndrome or undiagnosed illness or partially diagnosed or unexplained illness. This June 2017 examiner concurs with the previous examiner's report of May 2017 which states: "Therefore it is less likely than not (50 percent or less probability) that the Veteran has sleep apnea as a result of potential gulf war exposures, to include exposures to oil fires, smoke or fuel fumes as alleged by the Veteran in his statements in support of claim and by fellow service-members in buddy statements submitted in support of the Veteran's claim and it is more likely than not that the Veteran has sleep apnea as a result of his other multifactorial health conditions." The Board finds the July 2016, and June 2017 VA examinations and opinions are probative as they are sound and thorough, and had sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting medical literature and clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The June 2017 opinion thoroughly discussed both direct and secondary service connection, to include the possibility of the service-connected disabilities. Upon review of the evidence of record, the Board finds that the weight of the competent and probative evidence does not demonstrate that entitlement to service connection is warranted for the Veteran's claimed sleep apnea condition. The previously mentioned VA examinations find diagnoses of sleep apnea conditions, and thus the requirement for a current disability is met. However, there is no evidence in the record of a problem with sleep apnea until 2007, 16 years after active service. The Board finds that the VA medical opinions are the most probative evidence and demonstrate that the sleep apnea condition was not incurred in service and is not caused or aggravated by a service-connected disability. There are no positive nexus opinions from VA in the Veteran's claims file, and none from any private medical authority. See McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006); Bostain v. West, 11 Vet. App. 124 (1993). The Board notes the Veteran's and his buddies' statements that provide statements regarding the current condition of the Veteran and his asserted sleep apnea, but those observations do not include any opinion, competent or otherwise, as to the nexus of the Veteran's claimed sleep apnea. Generally, lay evidence is probative with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran can observe symptoms such as snoring, he is competent to comment on and endorse these symptoms. However, the determination of the etiology of sleep apnea is a complex medical determination beyond his competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. Because the Veteran has no in-service or related disease or injury that occurred in service or within one year after leaving active service that is not already accounted for in his other service-connected disabilities, the second prong of the test for entitlement to direct service connection is not met. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. . Further, the Board has considered the Veteran's contentions that his sleep apnea condition arose from his service-connected knee disabilities or his PTSD. The weight of the competent and probative medical opinions demonstrate that the service-connected conditions do not cause or aggravate the sleep apnea. Finally, with regard to the possibility of service connection via a Gulf War Illness analysis, per 38 C.F.R. § 3.317, the Board notes that the Veteran does meet the qualifying service requirement. However, his sleep apnea does not qualify as an undiagnosed illness or medically unexplained chronic multi-symptom illness. For a disability due to undiagnosed illness and medically unexplained chronic multi-symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2021. See 81 Fed. Reg. 71,384 (Oct. 17, 2016) (codified at 38 C.F.R. § 3.317(a) (1)). An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. See Gutierrez v. Principi, 19 Vet. App. 1 at 8-9 (2004). Here, in this case, the Veteran's sleep apnea is clearly a diagnosed illness, and was not diagnosed until 2008, over 16 years after the Veteran's Gulf War service. While the Board notes that sleep disturbances are a possible indication of chronic disability, objective indications of a chronic disability include objective evidence perceptible to an examining physician and non-medical indicators that can be independently verified. 38 U.S.C. § 1117. Lay evidence describing symptoms unsupported by clinical findings is sufficient to establish service connection for undiagnosed illness under 38 C.F.R. § 3.317, as long as there is no medical evidence indicating the symptoms are related to a known clinical diagnosis. Here, in this case, the Veteran has a diagnosis of sleep apnea based on symptoms first reported in 2007, and thus the Board finds that his claimed sleep apnea disability is not entitled to service connection via 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); see also Gutierrez v. Principi, 19 Vet. App. 1 (2004). Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed sleep apnea was not incurred in service and was not caused or aggravated by the Veteran's service-connected disabilities. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a sleep apnea condition on a direct, secondary, or Gulf War Illness basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. C. Evidence and Analysis -Headaches The Veteran received a Gulf War examination in September 2006, where he reported headaches. The Veteran had another complaint of headaches noted in a VA treatment note from April 2008. The Veteran received a compensation and pension examination in August 2010. Here, the Veteran reported chronic headaches which began in service after returning from the Gulf region but he did not recall a specific date for the onset of symptoms. He described the headaches as intermittent episodes of frontal headaches which occur 2-3 times a week, lasting 10-15 minutes at a time. The examiner noted there was no mention of headaches in the service treatment records, and he declined to make a diagnosis of headaches in this examination. In an opinion, the examiner opined it was less likely than not that the Veteran's headaches are caused or related to his military service. In June 2011, while receiving a VA examination for his PTSD, the Veteran noted headaches as "negative" in his questionnaire. In July 2011, in a VA treatment note, the Veteran remarked that since using his CPAP machine that his headache symptoms and frequency improved. The Veteran received a VA contract examination for his headaches in July 2016. The examiner noted the service treatment records that were available had no evidence of headaches relating to active military service. Additional symptoms reported include nausea, but no characteristics of migraine headaches were noted. The Veteran could not recall the specific date of the onset of symptoms. He reported that he did not seek medical evaluation in service for headaches. He indicated intermittent episodes of frontal headaches approximately 2 to 3 times per week that were triggered by lack of sleep. The examiner diagnosed headaches based on the Veteran's reported history but he opined that it was less likely than not (less than 50 percent probability) that they were related to active military service. The rationale was that the service records were silent for any headache issues, and the lack of specificity or history from the Veteran as to the possibility of a chronic condition. With regard to secondary service connection, the examiner remarked she could not opine beyond speculation because of the lack of history in the Veteran's record. The Veteran received a VA examination for his headaches, along with a Gulf War Illness general examination, in December 2016. This examination indicated no diagnosis of a chronic headache condition. The examiner noted the Veteran's complaints of headaches 2-3 times a week and taking over-the-counter ibuprofen to manage the headache pain. The examiner noted there were no prostrating attacks indicative of migraine headaches, and no aura was reported by the Veteran during his periodic headaches. The Veteran indicated his belief that being exposed to burn pits contributed to his headaches. The Veteran received an addendum opinion in June 2017 for the possibility of service connection for the claimed headache disability. Here, the examiner noted the Veteran has not been diagnosed formally with a specific headache condition from a treating provider in December 2016. Nevertheless, the characteristic description (with no type of aura and no prostrating attacks; a location across the frontal area of the scalp; the absence of non-headache symptoms associated with the headaches; a frequency of 2-3 times a week, and relief with non-steroidal agents such as Ibuprofen) all point towards a type of benign "muscle contraction" or typical "tension headache." In this particular Veteran, because the report of headaches came many years after his service separation, and because there is not a clear causal relationship to burn pit exposure, the examiner opined that it is less likely than not that the veteran has his headaches as a direct service connection in response to or causally related to or incurred in or during his active duty service. The examiner also opined that the Veteran's headaches are not secondarily related to some other condition or incident or service-connected entity, including his knee trauma and PTSD. The rationale for this is that there is no nexus to establish a causal relationship, and the other explanations of the multitude of other causative or contributing factors are legion. The Veteran's pattern of 2-3 headaches per week does not follow a pattern such that PTSD would be the likely cause or be the aggravating factor. Again, the examiner opined, idiopathic and muscular issues would be the predominant concerns for most individuals. Therefore, the examiner's conclusion is that the headaches described (which are most likely muscle contraction in nature) are less like than not to have a secondary service connection to any service-connected condition which the Veteran currently has. Furthermore, for the same reasoning, this examiner does not find a likely justification to warrant an "aggravating service connection" because it is felt to be less likely than not that the Veteran's non-service connected headaches are aggravated beyond their normal progression or beyond their natural course by any of the veteran's service-connected conditions. Finally, the examiner noted the Veteran suffers from headaches which are a "diagnosable condition" and are not felt to be a part of any particular syndrome or constellation of a multitude of unexplained symptoms. See 38 C.F.R. § 3.317. It is also this examiner's conclusion that the headaches described (which are most likely muscle contraction in nature) are less likely than not to have been caused by any Gulf-war or burn-pit exposure to toxic gases, fumes, fuels, oil fires, or smoke to which the Veteran was exposed, based on an extensive review of the medical literature. The Board finds the July 2016, and June 2017 VA examinations and opinions were sound and thorough, and had sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting medical literature and clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The June 2017 opinion thoroughly discussed both direct and secondary service connection, to include the possibility of the service-connected disabilities. Upon review of the evidence of record, the Board finds that the weight of the competent and probative evidence does not demonstrate that entitlement to service connection is warranted for the Veteran's claimed headaches condition. The previously mentioned VA examinations find diagnoses of headache conditions, and thus the requirement for a current disability is met. However, there is no evidence in the record of a problem with headaches until 2007, 16 years after active service. The Board finds that the VA medical opinions are the most probative evidence and demonstrate that the headache condition was not incurred in service and is not caused or aggravated by a service-connected disability. There are no positive nexus opinions from VA in the Veteran's claims file, and none from any private medical authority. See McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006); Bostain v. West, 11 Vet. App. 124 (1993). The Board notes the Veteran's and his buddies' statements that provide statements regarding the current condition of the Veteran and his asserted headaches, but those observations do not include any opinion, competent or otherwise, as to the nexus of the Veteran's claimed headache disability. The Board also notes the Veteran's consistent lay statements and other complaints in the record regarding his headaches, and notes also that headaches have been noted multiple times by VA. Generally, lay evidence is probative with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran can observe symptoms such as headache pain, he is competent to comment on and endorse these symptoms. However, the determination of the etiology of headaches is a complex medical determination beyond his competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. Because the Veteran has no in-service or related disease or injury that occurred in service or within one year after leaving active service that is not already accounted for in his other service-connected disabilities, the second prong of the test for entitlement to direct service connection is not met. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. . Further, the Board has considered the Veteran's contentions that his headache condition arose from his service-connected knee disabilities or his PTSD. The weight of the competent and probative medical opinions demonstrate that the service-connected conditions do not cause or aggravate the headaches. Finally, with regard to the possibility of service connection via a Gulf War Illness analysis, per 38 C.F.R. § 3.317, the Board notes that the Veteran does meet the qualifying service requirement. However, his headache condition does not qualify as an undiagnosed illness or medically unexplained chronic multi-symptom illness. For a disability due to undiagnosed illness and medically unexplained chronic multi-symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2021. See 81 Fed. Reg. 71,384 (Oct. 17, 2016) (codified at 38 C.F.R. § 3.317(a) (1)). An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. See Gutierrez v. Principi, 19 Vet. App. 1 at 8-9 (2004). Here, in this case, the Veteran's headache condition is a diagnosed illness, and was not noted until 2006, over 15 years after the Veteran's 1991 Gulf War service. While the Board notes that headaches are a possible indication of chronic disability, objective indications of a chronic disability include objective evidence perceptible to an examining physician and non-medical indicators that can be independently verified. 38 U.S.C. § 1117. Lay evidence describing symptoms unsupported by clinical findings is sufficient to establish service connection for undiagnosed illness under 38 C.F.R. § 3.317, as long as there is no medical evidence indicating the symptoms are related to a known clinical diagnosis. Here, in this case, the Veteran has a diagnosis of headaches based on symptoms first reported in 2006, and thus the Board finds that his claimed headache disability is not entitled to service connection pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); see also Gutierrez v. Principi, 19 Vet. App. 1 (2004). Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed headache condition was not incurred in service and was not caused or aggravated by the Veteran's service-connected disabilities. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a headache condition on a direct, secondary, or Gulf War Illness basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for headaches is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs