Citation Nr: 20072847 Decision Date: 11/12/20 Archive Date: 11/12/20 DOCKET NO. 16-57 223 DATE: November 12, 2020 REMANDED Entitlement to service connection for headaches, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Prior to July 10, 2020, entitlement to an initial rating in excess of 30 percent for service-connected PTSD is remanded. From July 10, 2020, entitlement to an initial rating in excess of 50 percent for service-connected PTSD is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran had active military service from October 1950 to October 1953. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In March 2020, the Veteran testified before a Board hearing. The transcript of the hearing is of record. By way of background, in May 2020, the Board denied the Veteran’s claim for entitlement to an earlier effective date for the grant of service connection for PTSD and entitlement to service connection for chronic pain disorder and remanded the issues on appeal. Additionally, the Board found that the issue of entitlement to a TDIU was raised by the evidence of record. Rice v. Shinseki, 22 Vet. App. 447 (2009). 1. Entitlement to service connection for headaches, to include as secondary to service-connected PTSD, is remanded. The Board concludes that the June 2020 VA medical opinion is insufficient because it does not address whether service-connected PTSD aggravated his headaches. In the June 2020 addendum opinion, the examiner opined that the Veteran’s headaches are less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that there is no diagnosis for chronic headaches as the objective examination revealed normal findings. The examiner further stated that there is no medical evidence showing that the Veteran had headaches in service or after separation from service. The Veteran denied having headaches in December 2001, May 2003, May 2005, February 2012, January 2015, April 2016, June 2016, August 2016, July 2018, September 2018, and February 2019. The examiner noted that there were two incidents wherein the Veteran complained of headaches. However, these complaints of headaches were accompanied by elevated blood pressure and when the Veteran mentioned stress due to an acute event. The examiner also opined that the Veteran’s headaches are less likely than not proximately due to, or the result of, the Veteran’s service-connected PTSD. The examiner explained that headaches and PTSD are not medically related as headaches are a separate entity entirely from PTSD. Further, a thorough review of the medical literature failed to demonstrate a causal relationship. Although the medical literature shows that those with PTSD have a higher likelihood of having headaches, the examiner stated that there is no causation between PTSD and headaches. Although causation is mentioned, aggravation is not. Accordingly, a remand for an addendum is needed. 2. Prior to July 10, 2020, entitlement to an initial rating in excess of 30 percent for service-connected PTSD is remanded. 3. From July 10, 2020, entitlement to an initial rating in excess of 50 percent for service-connected PTSD is remanded. The Board observes that the last time VA records were associated with the claims file was March 2019. The Veteran received regular psychiatric treatment from VA psychologist Dr. Douglas Bermingham. The Board concludes that a remand is necessary to obtain current records. 4. Entitlement to a TDIU is remanded. As TDIU is intertwined with the claim for PTSD, this matter will be remanded. The matters are remanded for the following action: 1. Develop the claim for TDIU. 2. Obtain all relevant outstanding VA treatment records, to include any relevant Vet Center records and psychiatric records, to include those from Dr. Bermingham, dated from March 2019 to the present. 3. Obtain an addendum to the June 2020 VA medical opinion regarding the claim for headaches. The examiner should opine as to whether it is at least as likely as not that his headaches are aggravated by his PTSD. In particular, the examiner should note the medical evidence indicating that the Veteran has reported headaches when his blood pressure was higher and he felt stress. It should be noted that concluding the Veteran does not have a diagnosis of chronic headaches or stating that medical literature does not show causation between PTSD and headaches is an insufficient rationale. The examiner is asked to note that in April 2016, the Veteran stated he had headaches when his blood pressure is higher. In September 2018, the Veteran complained of headache, and his blood pressure was elevated and he felt stress at the time. 4. Thereafter, readjudicate the claims for service connection for headaches, increased rating for PTSD, and entitlement to TDIU. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Noh, 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.