Citation Nr: 20002045 Decision Date: 01/09/20 Archive Date: 01/09/20 DOCKET NO. 18-05 717 DATE: January 9, 2020 ORDER Entitlement to service connection for migraine headaches, to include as secondary to service-connected disability, is denied. REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) due to military sexual trauma (MST) is remanded. FINDING OF FACT The preponderance of the evidence is against finding that migraine headaches began during active service, or are otherwise related to an in-service injury, event, or disease, or to a service-connected disability. CONCLUSION OF LAW The criteria for service connection for migraine headaches, to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 2002 to July 2006. On appeal is a September 2016 rating decision that denied service connection for migraine headaches and PTSD due to MST. Duty to Notify and Assist The Veteran has not raised any issues with the duty to notify. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (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 veteran fails to raise them before the Board”). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. Also of record are VA medical opinions obtained in July 2015, June 2016, March 2017, and July 2017. The Veteran has not referred to any additional, unobtained, relevant, available evidence. Thus, the Board finds that VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA’s duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection is also warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2018). Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). 1. Entitlement to service connection for migraine headaches, to include as secondary to service-connected disability. The Veteran contends that she is entitled to service connection for migraine headaches, to include consideration as to whether her migraine headaches were caused or aggravated by her service-connected allergic rhinitis. The Board has closely reviewed the medical and lay evidence in the Veteran’s claims file and finds no evidence that may serve as a medical nexus between the Veteran’s migraine headaches and her service or her service-connected allergic rhinitis. The Veteran’s service treatment records are associated with the claims file. The June 2001 enlistment Report of Medical History reflects the Veteran checked the box for “no” when asked if she had or ever had frequent or severe headaches. During service, two complaints of headaches were noted. A June 2005 record reflects a complaint of headache, along with asthma symptoms, and a diagnosis of allergies. An October 2005 record reflects a complaint of headache along with diagnoses of sinusitis and asthma. Records dated in February 2006 reflect the Veteran was referred to the Medical Evaluation Board for asthma. As part of the medical board proceedings the Veteran underwent a general examination in May 2006. The written report for that examination reflects a diagnosis of moderate persistent asthma, active bronchitis, allergic rhinitis, acute sinusitis, gastroesophageal reflux disease, and symptomatic lumbar spine arthralgia. There was no diagnosis of migraines or headaches. The Veteran’s post-service VA treatment records from the Loma Linda VAMC are associated with the file. A January 2015 record reflects the Veteran complained of a new onset of headaches, starting a couple of months ago. The headache pain was described as primarily located in the paranasal sinuses and occasionally the temples. The physician noted headache likely secondary to allergic rhinitis, possibly migraine in setting of sensitivity to light. A September 2015 active medication list reflects the Veteran takes medication for migraines. An October 2015 record reflects a complaint of migraines. A December 2016 medication list includes medication for migraines. The Veteran underwent a VA examination for headaches in July 2015. The examiner diagnosed the Veteran with migraine headaches and opined that the claimed condition is less likely than not proximately due to or the result of the Veteran’s service-connected endometriosis. As rationale, the examiner stated a review of medical literature identified multiple complications of endometriosis, but that list does not include migraines. The examiner also stated the underlying causes of migraines are unknown but are believed to be related to a mix of environmental and genetic factors. However, the examiner did not offer an opinion regarding whether the Veteran’s migraines are directly related to service, or to her service-connected allergic rhinitis, as she claimed. The Veteran underwent another VA examination for migraine headaches in June 2016, to address whether her migraine headaches were secondary to her service-connected allergic rhinitis. The examiner opined that the Veteran’s migraines are less likely than not proximately due to or the result of allergic rhinitis. As rationale, the examiner stated current literature does not provide an established pathophysiology suggesting allergic rhinitis causes migraines. The examiner also addressed whether the Veteran’s migraines were aggravated by her service-connected allergic rhinitis. The examiner opined that the Veteran’s migraines are less likely than not aggravated beyond its natural progression by her service-connected allergic rhinitis. As rationale, the examiner stated that based on thorough review of the claims file, including all available medical records, and current peer reviewed medical literature, there is no indication that the Veteran’s migraines are aggravated by her allergic rhinitis. The examiner explained that the Veteran has migraine headaches that are occasionally bothersome, and relieved by medication, with no indication that her allergic rhinitis aggravates her migraines. The Veteran underwent another VA examination for headaches in July 2017. The examiner gave an opinion on direct service connection as well as whether the Veteran’s migraine headaches were secondary to her service-connected depression. As to direct service connection, the examiner opined that the condition claimed was less likely than not incurred in or caused by service. As rationale, the examiner noted that the Veteran’s service treatment records are silent with regard to migraine headaches. While Veteran claimed frequent or severe headaches at discharge, the examiner found no evidence to support their relation to service, no clinical notes documenting headaches or headache diagnosis in service, and no evidence of the Veteran being prescribed any medication to treat such headaches in service. As to service connection secondary to depression, the examiner opined that the Veteran’s migraines are less likely than not proximately due to or the result of her service-connected disability. As rationale, the examiner stated that migraines headaches are a distinct pathophysiologic phenomenon, and as such while they may be triggered by psychological stress, among many other factors, they are not caused by psychological stress, and the Veteran did not associate her migraines with her mental health condition at her examination. Direct Service Connection In light of the evidence noted above, the Board concedes that the Veteran has a current diagnosis of migraine headaches. However, the Board notes that none of the Veteran’s treatment providers have provided an opinion that any such disability is directly related to her military service. There is simply no competent medical evidence of record to suggest that the Veteran’s migraine headaches are in any way related to her time on active duty. Thus, in this case, when weighing the evidence of record, the Board finds compelling the lack of evidence linking the Veteran’s migraine headaches to her military service on a direct basis. To be clear, the Board notes that the Veteran had two complaints of headaches during service. However, when considered in context, each of these complaints were given in association with symptoms, and diagnoses, other than a migraine or headache condition; rather, the headaches were noted to be associated with diagnoses of allergies, sinusitis and asthma. Also, the Veteran was noted to be separated from service because of asthma, with no mention of migraines or headaches. In this case, the only evidence in favor of the Veteran’s claim is her own statements concerning her belief that her migraine headaches, diagnosed approximately 10 years after service, are due to service. With regard to the Veteran’s contentions, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, it falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran is competent to report symptoms of migraine headache pain, the claimed disability is not the type of condition that is amenable to lay determination regarding its etiology, as specific findings are needed to properly determine etiology. Id. As such, the Board finds that, other than the Veteran’s unsupported contentions, there is simply no evidence in the record of any etiological relationship between the Veteran’s migraine headaches and her time in service. Thus, the criteria for service connection for migraine headaches on a direct basis have not been met. The evidence weighs against the Veteran’s claim. Service connection for migraine headaches on a direct basis must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Secondary Service Connection Regarding the Veteran’s claim that her migraine headache condition was caused or aggravated by her service-connected conditions of endometriosis, allergic rhinitis, and depression, VA obtained a medical opinion in July 2015, June 2016, and July 2017 to address these questions. As noted above, after review of the Veteran’s file, the July 2015 examiner opined that the Veteran’s migraine headache condition is less likely than not caused or aggravated by her endometriosis, finding no support for such a finding upon a review of medical literature and examination. Similarly, the July 2016 examiner opined that the Veteran’s migraine headache condition is less likely than not caused or aggravated by her allergic rhinitis, finding that current literature does not provide an established pathophysiology suggesting allergic rhinitis causes migraines. Finally, the July 2017 examiner opined that the Veteran’s migraine headache condition is less likely than not caused or aggravated by her depression, finding that migraines are a distinct pathophysiologic phenomenon, and while they may be triggered by psychological stress, among many other factors, they are not caused by psychological stress. A review of the post service treatment records from the Loma Linda VAMC reflect the Veteran has been diagnosed with migraine headaches and treated with medication. However, none of these records provide a nexus or link between the Veteran’s migraine headaches and her service-connected endometriosis or depression. In so finding, the Board acknowledges a January 2015 record in which a physician noted the Veteran’s “headache likely secondary to allergic rhinitis, possibly migraine in setting of sensitivity to light.” With only this statement, and no supporting rationale, the Board has assigned more probative weight to the opinion of the June 2016 examiner that the Veteran’s migraine headaches are not secondary to her service-connected allergic rhinitis. The June 2016 examiner indicated in his written report that the Veteran’s medical records were reviewed, her reported history was considered, an examination was conducted, and medical literature was reviewed. In this case, the only evidence in favor of the Veteran’s claim is her own statements concerning her belief that her migraine headache condition, diagnosed almost 10 years after service, is due to her service-connected disabilities. With regard to the Veteran’s contentions, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, it falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran is competent to report symptoms of migraine or headache pain, the claimed disability is not the type of condition that is amenable to lay determination regarding its etiology, as specific findings are needed to properly determine etiology. Id,; see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As such, for the reasons noted above, the Board finds that the weight of the competent, probative evidence of record does not support a finding that there is any etiological relationship between the Veteran’s current migraine headaches and her service-connected endometriosis, allergic rhinitis, or depression. Thus, the criteria for service connection for migraine headaches, secondary to service-connected disability, have not been met. The evidence weighs against the Veteran’s claim. Service connection for migraine headaches must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). REASONS FOR REMAND 1. Entitlement to service connection for PTSD due to MST is remanded. The Board finds that additional development is needed before a decision may be rendered on the issue of service connection for PTSD due to MST. In her July 2016 Statement in Support of Claim for PTSD and again in her March 2017 VA examination and her January 2018 substantive appeal, the Veteran stated that while stationed at Fort Jackson, she was raped by someone she did not know. More specifically, the Veteran stated that she was on the cleaning crew when someone came in the bathroom as she was cleaning a toilet stall and forced himself on her. She states she sought treatment shortly thereafter because she kept getting sick and was informed that she was pregnant. The Veteran also indicated there were pregnancy tests around the time of the incident to support her claim. In light of the Veteran’s statements, the Board finds that there may be additional records during her period of service that support her claim, namely medical records from Tri-Care Clinic and Planned Parenthood. In addition, there may also be additional service treatment records that include pregnancy tests. On remand, these records are to be obtained and associated with the Veteran’s case file. The Veteran is also advised that she may want to consider obtaining “buddy statements” from the officer she confided in, and from the buddy that took her to have the procedure done at Planned Parenthood. Lastly, the Board notes that the March 2017 VA examination was internally inconsistent in the Veteran was assigned diagnoses of both PTSD and depressive disorder, for which she is separately service connected. However, the examiner also stated the Veteran does not have more than one mental disorder diagnosed. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). On remand, a new VA examination must be obtained. The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran’s file any outstanding service treatment records and private treatment records, to specifically include pregnancy tests, termination of pregnancy records, and any evidence of MST, from the Veteran’s treating Tri-Care clinic and from the Planned Parenthood where she sought treatment after the incident. 2. Allow the Veteran the opportunity to obtain “buddy statements” from the officer to whom she reported the assault, as well as the buddy who accompanied her to Planned Parenthood. 3. After the above development has been completed, schedule the Veteran for a VA examination to address the nature and etiology of any acquired psychiatric disability other than depressive disorder found to be present. The examiner is asked to identify all diagnosed psychiatric disabilities found to be present at any point during the appeal period. For each such disability diagnosed, to include PTSD, the examiner must provide an opinion as to whether it is at least as likely as not that any such diagnosed psychiatric disability is causally related to active service. In so finding, the examiner must clarify the findings of the March 2017 VA examiner, who first diagnosed the Veteran with both PTSD and depressive disorder and then stated that the Veteran has only one psychiatric disability. In reconciling these findings, the examiner must determine the correct diagnosis, or diagnoses, of each acquired psychiatric disability the Veteran experiences. If no diagnosis of PTSD is found to be appropriate, the examiner must clarify whether all symptoms attributable to such a diagnosis are accounted for by the Veteran’s service-connected depressive disorder. A complete rationale must be given for all opinions and conclusions expressed. The examiner is advised that the Veteran is competent to report history and symptoms, and that her reports must be considered in formulating the requested opinion. If the examiner rejects the Veteran’s reports, he or she must provide a rationale for doing so. Caroline B. Fleming Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Jiggetts, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.