Citation Nr: 20004917 Decision Date: 01/23/20 Archive Date: 01/22/20 DOCKET NO. 17-52 649 DATE: January 23, 2020 REMANDED Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1987 to March 1997. He served in the United States Air Force. In October 2019, the Veteran and his wife appeared at a Board hearing and testified before the undersigned Veterans Law Judge. 1. Entitlement to service connection for headaches is remanded. First, remand is required to attempt to obtain additional records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2014); 38 C.F.R. § 3.159(c) (2018). VA’s duty to assist includes making reasonable efforts to obtain private medical records. 38 C.F.R. § 3.159(c)(1). At the October 2019 Board hearing, the Veteran testified that he received care from two neurologists. The Veteran indicated that one of them was a private neurologist in Corvallis. The Veteran’s VA treatment records show that the Veteran had been formerly been followed by neurologist Dr. G.R. at the Corvallis Clinic. It does not appear that the RO have attempted to obtain these records. Therefore, on remand, the RO must make reasonable efforts to obtain any outstanding records from neurologist Dr. G.R. from the Corvallis Clinic. Second, remand is required for an adequate examination. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran alleges that his headaches had onset in active service. The Veteran’s service treatment records (STRs) showed that he complained of headaches. See STRs from June 1995, November 1996. During the October 2019 Board hearing, the Veteran testified that he experienced headaches during active duty and that they continued to get worse after service. The Veteran further testified that he did not seek treatment for headaches until they got really bad. The Veteran reported that he still had headaches today, and had to get shots for them. The Veteran stated that his VA neurologist told him that his current headaches could or may be related to active duty. The Veteran testified that a different VA treatment provider asked him if he was around a lot of explosions in the military. The Veteran stated that he was, explaining that during the first four years of service, he was a part of a base recovery where they blew up runways every week and used ground burst simulators on a regular basis. The Veteran also stated that he used a lot of CS gas all the time because of training for chemical warfare and because of the wind shifts, he got gassed quite a bit. The Veteran testified that after the provider heard his military history, the provider stated that the events could be the cause of his headaches. A June 2016 VA opinion was obtained without an in-person examination. The Veteran was diagnosed with migraines, including migraine variants. The examiner opined that the Veteran’s claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that all in-service headaches were transient symptoms as part of a viral illness or related to the Veteran’s eyeglasses. The examiner also stated that there was no record of a chronic headache disability or of migraine headaches in-service. The examiner also cited VA treatment records from 2007 and 2009 wherein the Veteran reported the onset of his headaches was in 2006, which was well after active duty. The examiner concluded that there was no relationship to the Veteran’s in-service activities. However, without an in-person examination, the examiner was unable to consider the Veteran’s lay statements regarding the onset of and continuity of his symptoms during and post-service. Additionally, the examination report does not address if the Veteran’s headaches could be related to the Veteran’s proximity to explosions and exposures to gases. For the foregoing reasons, a new VA examination is warranted. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. A specific request should be made for medical records from neurologist Dr. G.R. at the Corvallis Clinic. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, schedule the Veteran for a VA examination to assist in determining the etiology of all headache disorders. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must elicit from the Veteran a full history and/or description of his active service, including his proximity to explosions and exposure to gases. (a.) For each currently diagnosed headache disorder, the examiner must opine whether is it at least as likely as not (a 50 percent or greater probability) that the disorder manifested in or is otherwise related to the Veteran’s military service, to include exposure to gases and explosions. The examiner must consider and address the following: 1) the October 2019 Board hearing testimony; 2) Veteran’s lay statements describing his in-service symptoms; 3) his post-service symptoms; 4) the June 2016 VA examination report; 5) the Veteran’s VA treatment records showing treatment for headaches; and 6) the Veteran’s STRs showing complaints of headaches in service. 4. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2018). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Nguyen, 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.