Citation Nr: 20027751 Decision Date: 04/21/20 Archive Date: 04/21/20 DOCKET NO. 15-00 041 DATE: April 21, 2020 REMANDED Entitlement to service connection for headaches, to include as secondary to the service-connected degenerative joint disease of the cervical spine (cervical spine disability) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1986 to August 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2013, the Veteran testified at a hearing before a Decision Review Officer. In February 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Transcripts of both hearings are of record. This matter was previously before the Board in December 2018, when it denied entitlement to service connection for headaches, to include as secondary to the service-connected cervical spine disability. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). In September 2019, pursuant to a Joint Motion for Remand (Joint Motion), the Court vacated the December 2018 Board decision and returned the claim to the Board for actions consistent with the Joint Motion. 1. Entitlement to service connection for headaches, to include as secondary to the service-connected cervical spine disability The Veteran seeks entitlement to service connection for a headache disability, to include as secondary to his service-connected cervical spine disability. The Board notes that entitlement to service connection for a cervical spine disability was established in a September 2005 rating decision. In the September 2019 Joint Motion, the parties determined that the Board erred by failing to provide an adequate statement of reasons or bases for its finding that VA substantially complied with the Board’s July 2018 remand instructions, citing Stegall v. West, 11 Vet. App. 268, 261 (1998). More specifically, the parties noted that the Board instructed VA to obtain an opinion addressing if it was at least as likely as not that the Veteran’s headaches are worsened beyond natural progression (aggravated) by his service-connected cervical spine disability. The parties determined that, while a VA opinion was obtained in October 2018 pursuant to the remand instruction, the October 2018 VA examiner never explicitly opined whether the Veteran’s service-connected cervical spine disability aggravated his headache disability. In order to address the concerns raised in the September 2019 Joint Motion, the Board finds a remand is warranted to obtain a new VA opinion regarding aggravation. Additionally, the Board notes that, subsequent to the Joint Motion, additional evidence has been added to the record, including February 2020 correspondence from the Veteran asserting his headache disorder is related to a February 1989 motor vehicle accident during service, and medical articles submitted in February 2020, which he asserts support his contentions. The Board notes that service treatment records dated in February 12, 1989, February 13, 1989 and February 21, 1989 reflect treatment following a February 1989 motor vehicle accident. Notations pertain to a bump to the back of the head (occipital contusion) and query of possible concussion; no headache complaints are noted. As such, the Board finds a VA opinion addressing direct service connection is warranted. Updated treatment records should also be requested. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed headache disability. After securing any necessary releases, request any relevant records identified that are not duplicates of those associated with the claims file. In addition, obtain updated VA treatment records from October 2018. If any requested records are unavailable, the Veteran should be notified of such. 2. After records development is completed, provide the claims file to a VA neurologist to obtain a new opinion on the claim for service connection for a headache disability. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. After reviewing the claims file, the neurologist should respond to the following: (a.) For each headache disorder identified, is it at least as likely as not (50 percent probability or greater) that the headache disorder arose during service or is otherwise related to service? The examiner must explain why or why not, to include addressing the significance, if any, of service treatment records in February 1989 reflecting treatment following a motor vehicle accident and noting an occipital contusion and query of possible concussion, and whether a currently diagnosed headache disorder is a subsequent manifestation of such injury. The examiner is also asked to address the Veteran’s contentions that medical research reflects a positive correlation between headaches and head injury (see appellant correspondence and medical article submissions, received February 21, 2020). (b.) If not related to service, is it at least as likely as not that a current headache disorder was caused by the service-connected cervical spine disability? The examiner must explain why or why not, to include addressing the Veteran’s contentions that his headaches occur simultaneous to and are caused by neck pain, and that medical research reflects a positive correlation between headaches and cervical degenerative disease (see appellant correspondence and medical article submissions, received February 21, 2020). (c.) If not caused by the service-connected cervical spine disability, is it at least as likely as not that the current headache disorder was worsened (aggravated) beyond natural progression by the service-connected cervical spine disability? The examiner must explain why or why not, to include addressing the Veteran’s contentions that his headache symptoms worsen as his neck pain increases; and that medical research reflects a positive correlation between headaches and cervical degenerative disease (see appellant correspondence and medical article submissions, received February 21, 2020). (d.) If the examiner finds that the current headache disorder was aggravated by the service-connected cervical spine disability, the examiner should attempt to quantify the level of aggravation beyond the baseline level of the headache disorder. The examiner should provide a rationale for all opinions and conclusions expressed. 3. If the claim remains denied, issue a supplemental statement of the case, as appropriate. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. C. Birder 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.