Citation Nr: 20037597
Decision Date: 06/02/20	Archive Date: 06/02/20

DOCKET NO. 16-56 180
DATE: June 2, 2020

REMANDED

Entitlement to service connection for headaches, to include as secondary to an acquired psychiatric disorder including posttraumatic stress disorder (PTSD) and/or major depressive disorder, is remanded.

REASONS FOR REMAND

The Veteran served on active duty from July 1974 to July 1976 and from May 1990 to May 1991.  This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).  The Board remanded the claim in December 2018 for development.

Entitlement to service connection for headaches, to include as secondary to an acquired psychiatric disorder including posttraumatic stress disorder (PTSD) and/or major depressive disorder.

The Veteran contends that his headaches are related to his service-connected PTSD.  A March 1997 report of medical history shows that the Veteran reported headaches since returning from Desert Storm.  A June 2017 private opinion related headaches to depressive disorder.  The Board remanded the claim in December 2018 to afford the Veteran a VA examination.  In August 2019, the Veteran reported that he did not receive timely notice for the VA examination.  A remand is warranted to afford the Veteran a VA examination.

The matters are REMANDED for the following action:

1. Ask the Veteran to provide the names and addresses of all medical care providers who have treated him for his headaches.  After securing any necessary releases, request any relevant records identified.  Updated VA treatment records should also be obtained.  If any requested records are unavailable, the Veteran and his representative should be notified of such. 

2. After records development is completed, obtain a medical opinion from a qualified examiner with respect to the Veteran’s claim for service connection for headaches.  After review of the claims file, the examiner should address the following:

(a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s headaches arose during service or are otherwise related to his active military service?  The examiner should explain why or why not.

(b.) If headaches did not arise in active service or are not related to service, the examiner should opine whether it is at least as likely as not that the Veteran’s headaches are caused or aggravated by his service-connected PTSD.  Please explain why or why not.

(c.) If the examiner finds the headaches have been aggravated by the service-connected PTSD, the examiner should attempt to quantify the degree of aggravation beyond the baseline level of the headaches.

Th examiner is advised that the Veteran is competent to report symptoms capable of lay observation.  The examiner is asked to discuss the March 1997 report of headaches since returning from Desert Storm and the June 2017 opinion relating headaches to depressive disorder.

 

 

MICHELLE P. KATZ

Acting Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	A. Asare, 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.