Citation Nr: 20022366 Decision Date: 03/31/20 Archive Date: 03/31/20 DOCKET NO. 19-29 967 DATE: March 31, 2020 REMANDED Entitlement to an initial disability rating in excess of 10 percent for residuals of a traumatic brain injury (TBI) (previously characterized as residuals of a TBI with migraine headaches prior to October 23, 2008) is remanded. Entitlement to an initial compensable rating for migraine headaches associated with residuals of a TBI from October 23, 2008 to July 30, 2019; and in excess of 10 percent on and after July 31, 2019, is remanded. REASONS FOR REMAND The Veteran had active duty service in the United States Army from October 1989 to October 1992. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a November 2016 rating decision. The November 2016 rating decision granted entitlement to service connection for residuals of a TBI with migraine headaches and assigned an initial 10 percent disability rating effective from September 11, 2006. During the pendency of the Veteran’s appeal of this assigned rating, an August 2019 Decision Review Officer (DRO) decision recharacterized the disability as residuals of a TBI effective from October 23, 2008. The rating decision also assigned a separate noncompensable rating for migraine headaches effective from October 23, 2008 July 30, 2019; and a 10 percent rating on and after July 31, 2019. 1. Entitlement to an initial disability rating in excess of 10 percent for residuals of a TBI (previously characterized as residuals of a TBI with migraine headaches prior to October 23, 2008); and entitlement to an initial compensable rating for migraine headaches associated with residuals of a TBI from October 23, 2008 to July 30, 2019; and in excess of 10 percent on and after July 31, 2019, are remanded. The Veteran was last provided with VA examinations to evaluate his residuals of a TBI and migraine headaches in July 2019. During the examination for migraine headaches, the examiner stated that the Veteran experienced severe migraine headaches approximately every other month. During the examination related to the TBI, the examiner noted that the Veteran did not have any complaints of impairment of memory, attention, concentration, or executive functions. The Veteran has since asserted that he experiences severe headaches three times a month. See January 2020 Statement. He also reported that he has both short-term and long-term memory problems. See January 2020 Statement. Although the Veteran attributed these memory difficulties to his separately service-connected posttraumatic stress disorder (PTSD), it is unclear whether this complaint is a residual of his TBI. As these reports at least suggest a worsening in the severity of the Veteran's migraine headaches and residuals of a TBI since the July 2019 VA examinations, the Board finds that additional VA examinations should be obtained on remand. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his migraine headaches and residuals a TBI. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records, to include records dated since June 2019. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected migraine headaches. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the disability under the rating criteria. Specifically, the examiner should address the frequency and duration of the Veteran's migraine headaches, including the frequency of prostrating attacks and whether those attacks are productive of severe economic inadaptability. 3. After completing the preceding development in paragraph 1, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected residuals of a TBI. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner should include an evaluation for each of the aspects that are characteristic of a TBI (cognitive, emotional/behavioral, and physical). To the extent possible, the examiner should distinguish which symptoms are attributable to the Veteran's service-connected TBI as opposed to his service-connected PTSD or any other nonservice-connected disorder. If the examiner is unable to distinguish the symptomatology, the examiner should so state in the report and provide an explanation. 4. After the development requested has been completed, review the medical reports to ensure that they are in compliance with the directives of this Remand. If the report is deficient in any manner, implement corrective procedures. 5. Then readjudicate the claim. If the benefit is not granted, the Veteran must be furnished a supplemental statement of the case. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.C. Spragins, 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.