Citation Nr: 20076844 Decision Date: 12/03/20 Archive Date: 12/03/20 DOCKET NO. 14-14 992 DATE: December 3, 2020 REMANDED Service connection for migraine headaches.   REASONS FOR REMAND The Veteran served on active duty from May 1990 to November 1991. The case is on appeal from a March 2011 rating decision. The record reflects that, in October 2020, the Veteran received a letter indicating that she could request a virtual tele-hearing instead of waiting for a Travel Board hearing. Upon further review, the record reflects that the Veteran does not have a pending hearing request as she has already provided testimony in a hearing before the undersigned Veterans Law Judge in June 2017. The transcript of such hearing has been considered as evidence ever since. Most recently, in March 2019, the Board remanded the present appeal for further development. Service connection for migraine headaches. In the March 2019 remand, the Board requested a VA opinion in connection with the present claim. The Board specifically requested from a medical professional to provide an opinion as to whether the claimed headaches disability was consistent with either a diagnosable but medically unexplained chronic multi-symptoms illness (MUCMI) or unknown etiology; a diagnosable chronic multi-symptom illness with a partially explained etiology; or attributable to a known, clear and specific diagnosis. The Veteran was afforded a VA examination in October 2019. She reported that her headaches began around 1992 and that she began to self-treat it with OTC medication. The Veteran indicated that while serving in Southwest Asia (SWA) she was exposed to burn pits and burning oil fields and that headaches began after this exposure. The VA examiner opined that the Veteran’s migraine headaches disability, which have known triggers and causes, is not related to exposure to burn pits fumes or other types of fumes she may have encountered during service in SWA as her service records are silent for such exposure. The examiner indicated that he could not find any mention of fumes or burn pits and that it was not until May 26, 1999, that the Veteran’s migraine headaches were first noted in her record when she saw a neurologist. The examiner further noted that the Veteran had previously mentioned that her headaches began in 1996, and during the examination she indicated that her headaches began in 1992, which “is a discrepancy in the history of headache onset.” The Board finds that the October 2019 VA opinion is not wholly adequate to decide the Veteran’s claim at this time. First, while the examiner indicated that the Veteran’s migraine headaches have “known triggers and causes,” the VA examiner did not list an etiology nor specific triggers and/or causes that could be potentially applicable to the Veteran’s individual circumstances. Thus, the question as to the nature and etiology of her migraine headaches, to some extent, still remains unanswered. Moreover, the examiner also noted that it was not until May 1999 that the Veteran’s migraine headaches were first noted when she saw a neurologist. However, such information appears to be based on inaccurate or incomplete information as service treatment records (STRs) show that during the Veteran’s July 1991 separation medical exam, she reported frequent or severe headaches which she described as “severe headaches for the past 3 weeks.” Another medical opinion is warranted. In a November 2020 brief, the Veteran’s representative VSO raised a theory of entitlement to service connection on a secondary basis with supporting evidence. He specifically stated that that the Veteran’s migraine headaches should also be considered as secondary to her service-connected posttraumatic stress disorder (PTSD). As to the newly raised theory of service connection on a secondary, in the November 2020 brief the Veteran’s representative made reference to articles and medical literature linking the two. See https://americanheadachesociety.org/news /post-traumatic-stress-disorder-ptsd-migraine/ (noting that PTSD symptoms precede migraine symptoms in almost 70% of those with migraine and PTSD); https://headaches.org/2008/06/15/ptsd-linked-to-chronic-headache/ (noting that studies revealed that depression is significantly higher in people with chronic migraine and so is PTSD). The Board notes that a November 2019 VA PTSD examination report reflects that the Veteran’s chronic migraines amplifies and exacerbates her mental health problems. The medical opinion should also address this theory. In light of the remand, any updated VA treatment records should also be obtained. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records dated since May 2020. 2. Thereafter, forward the claims file to a neurologist to determine the nature and etiology of all headache disorders experienced by the Veteran. If the physician deems it necessary, schedule the Veteran for a VA examination (or telehealth interview, records review, etc., if an in-person examination is not feasible). Based on the results of the file review, the physician is asked to address each of the following questions: (a) State whether the symptoms of the claimed condition (headaches) are attributable to a known clinical diagnosis. (b) Is the Veteran’s disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multi-symptoms illness (MUCMI) or unknown etiology and pathology, (2) a diagnosable chronic multi-symptom illness with a partially explained etiology and pathology, or (3) a disease with a clear and specific etiology and pathology diagnosis? (c) If, after reviewing the Veteran’s claim file, the examiner determine that the Veteran’s disability pattern is either (2) a diagnosable chronic multi-symptom illness with a partially explained etiology and pathology, or (3) a disease with a clear and specific etiology and pathology diagnosis, then provide an opinion as to whether it is related to any environmental hazard exposures experienced by the Veteran during her service in Southwest Asia. (d) If no to (c)(2) or (3), the examiner should provide an opinion as to whether it is at least as likely as not (probability of 50 percent or greater) that the condition had its onset during service or is otherwise casually related to service. (e) If no to (d), the examiner should then provide an opinion as to whether it is at least as likely as not the disability was caused by, or aggravated by, the Veteran’s service-connected PTSD. Consideration should be given to: (1) the Veteran’s statements throughout the pendency of the appeal as to the onset of her disability; (2) the July 1991 separation medical examination showing “severe headaches for the past 3 weeks; and (3) the medical literature cited the Veteran’s representative in support of nexus on a secondary basis. A detailed rationale for all opinions expressed should be provided. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board William Pagan, 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.