Citation Nr: 20032648 Decision Date: 05/08/20 Archive Date: 05/08/20 DOCKET NO. 14-37 274 DATE: May 8, 2020 REMANDED The issue of entitlement to a compensable rating prior to November 27, 2019, and a rating in excess of 30 percent as of November 27, 2019, for migraine headaches is remanded. REASONS FOR REMAND The Veteran had active service from March 1990 to August 1998. He served in Southwest Asia. The Veteran appeared at a February 2018 videoconference hearing before the undersigned Veterans Law Judge. The hearing transcript is of record. The issue of entitlement to a compensable rating prior to November 27, 2019, and a rating in excess of 30 percent as of November 27, 2019, for migraine headaches is remanded. In the June 2013 notice of disagreement, the Veteran reported that “the migraines interfere with my life as they are debilitating causing vomiting and not allowing me to participate in family things with my children and wife and at work.” At the February 2018 Board of Veterans’ Appeals (Board) hearing, the Veteran testified that: he was retired; when he was employed, he missed work “maybe once or twice a month” due to migraine headaches; and he experienced migraines headaches “probably twice a month, three times a month” which “actually makes me curl up in a ball.” The report of a November 2019 headaches examination conducted for the Department of Veterans Affairs (VA) states that the Veteran experienced characteristic prostrating attacks of migraine headache pain “once every month” and the headaches lasted more than two days. The examiner commented that: the Veteran was employed as a “tire tech;” had “0-1 week work time lost in last 12 months;” and “reports his migraine headaches make it difficult for him to go to work at times” as “he often has to retreat to a dark area to get symptom relief when he has a migraine headache.” The nurse-practitioner did not note or otherwise address the Veteran’s written statements and testimony that he experienced migraine headaches two to three times a month which made him “curl up in a ball” and unable to go to work “once or twice a month.” Because of that discrepancy, the Board finds that the February 2019 examination report is of limited probative value. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). When obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Because of the cited deficiency in the February 2019 examination report, the Board finds that further VA migraine headache evaluation is necessary. Clinical documentation dated after November 2019 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated him for the service connected migraine headaches. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA clinical documentation not already of record, including treatment records dated after November 2019. 3. Schedule the Veteran for a VA examination with a medical doctor to assist in determining the nature and severity of service-connected migraine headaches. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (Continued on the next page)   (a) Report the number and frequency of characteristic prostrating attacks, if any, during all relevant periods and any associated economic inadaptability as a result of the headaches. (b) Opine as to the impact of the disability on the Veteran’s vocational pursuits. If the Veteran is not currently employed, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran is unable to secure or follow a substantially gainful occupation due to the service-connected disabilities. If the Veteran is felt capable of work despite the service-connected disabilities, the examiner should describe what type of work and what accommodations would be necessary due to the service-connected disabilities. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. T. Hutcheson, 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.