Citation Nr: 20054470 Decision Date: 08/17/20 Archive Date: 08/17/20 DOCKET NO. 13-22 098 DATE: August 17, 2020 REMANDED Service connection for headaches.   REASONS FOR REMAND The Veteran served on active duty from June 1981 to September 1992, with additional service in the Army Reserves. The case is on appeal from a November 2010 rating decision. In March 2016, the Veteran testified at a Board hearing. The claim was previously before the Board in July 2016 and September 2018, and the issues of service connection for PTSD and headaches were remanded for additional development and VA examinations. The Veteran’s claim of service connection for PTSD was granted in a January 2020 rating decision. As this grant represents a full grant of the benefits sought, this issue is no longer on appeal. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). Service connection for headaches. The Veteran contends that the headaches she experiences are related to service, either as a direct result of her active duty, or secondarily to a service-connected disability. At her March 2016 Board hearing, the Veteran testified that while she was in service, she was informed she had migraines. In an August 2018 brief, the theory was raised of secondary service connection, to include whether medication to treat service-connected disabilities caused or aggravated the Veteran’s headaches. Based on this contention, the Board remanded the claim in September 2018 to obtain a new VA examination and medical opinion. The Veteran was afforded a new VA examination in October 2019. The Veteran was found to have a diagnosis of headaches not otherwise specified. The Veteran stated that the headaches stemmed from mental and physical traumatic abuse during the Gulf war. The examiner reported that the September 1980 enlistment exam noted frequent or severe headaches with provider comments that she “used to have headaches and dizzy spells,” and at the time of active military separation in July 1992, she again positively indicated a history of frequent or severe headaches. The examiner opined that her current headache condition was less likely as not aggravated beyond its natural progression with the rationale that the Veteran did not seek treatment for headaches that were “problematic” during service, nor was there treatment post-military to support a condition being aggravated beyond the natural progress of the disease. Further, the examiner stated her headache condition was less likely than not “due to any service connected conditions as there is no pathophysiological causal relationship linking the headaches to any condition as there are no concurrent complaints in the medical records.” The Board finds that another remand is warranted for a new medical opinion. First, it is noted that service connection for PTSD was granted in January 2020, and the October 2019 examiner did not have the opportunity to consider whether the Veteran’s headaches might be secondary to her PTSD. Second, the examiner did not fully address critical evidence in the file when opining that there are no concurrent complaints in the medical records between the Veteran’s headaches and other service-connected disabilities. In a November 2016 medical CAPRI document, the Veteran requested long-term therapy for anxiety and panic attacks, and it was reported that she “endorsed the following accompanying symptoms: sweating, shortness of breath, headaches, and slurred speech” (emphasis added). Also, at her June 2018 examination for fibromyalgia, current symptoms of the service-connected disorder included extreme joint stiffness, fatigue, and pulsating headaches. Further, it does not appear that the October 2019 examiner gave proper consideration of the Veteran’s lay statements reporting headaches during service in the Persian Gulf, as well as claimed headaches that accompany her service-connected psychiatric disability. In an October 2009 statement in support, she claims that her headaches may be due to medicine provided to combat nerve gases and exposure to environmental contaminants in Kuwait. In her November 2010 notice of disagreement, she stated that her anxiety and panic attacks include migraine headache symptoms. At her July 2016 VA examination for PTSD, when she was asked whether she took time off due to mental health issues, she stated, “I take time off because of bad headaches and because I don’t sleep well at night due to dreams.” Finally, in July 2019 correspondence while discussing triggers for her PTSD, she described her response to the triggers as “I can actually feel the squeezing of my brain . . .” Thus, the Board finds the October 2019 VA examination to be inadequate for failure to fully address this evidence in the record, and a new medical opinion is warranted. Barr v. Nicholson, 21 Vet. App. 303 (2007). In light of the remand, updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records dated since June 2019. 2. Forward the claims file to an appropriate medical professional for an opinion as to the nature and etiology of the Veteran’s headache condition. The need for an in-person examination (or telehealth interview if an in-person examination is not feasible) of the Veteran should be determined by the examiner. The record, including a complete copy of this remand, should be made available for review. (a) The examiner should first identify the Veteran’s current headache disorder. (b) Next, the examiner should provide an opinion as to whether any headache condition clearly and unmistakably (undebatable from a medical perspective) preexisted the Veteran’s service. If the examiner finds it did clearly and unmistakably preexist service, the examiner should provide an opinion as to whether it was clearly and unmistakably not aggravated by service. Aggravation is an increase in severity beyond the natural progress of the disease or temporary flare-up. “Not” aggravated cannot be shown solely by no evidence of aggravation. (b) If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner should then opine whether it is at least as likely as not (a 50 percent or greater probability) that her headache condition: (i) had its onset during service, or is otherwise related to, active service, or (ii) is caused or aggravated by a service-connected disability, to include PTSD or fibromyalgia. (iii) The examiner should also address whether any headache symptoms are also part and parcel of the Veteran’s service-connected PTSD or fibromyalgia. Consideration should be given to, and the examiner is requested to comment on: (1) the Veteran’s lay statements reporting symptoms of headaches during active service, and reporting headache symptoms since separation in conjunction with her psychiatric disability; (2) the November 2016 medical CAPRI document noting headaches as an accompanied symptoms of anxiety and panic attacks; (3) the June 2018 VA examination finding headaches as a symptom of fibromyalgia; and (4) any side effects of medications prescribed for any service-connected disability. If the absence of record treatment following separation plays a role in the formation of the opinion, the medical importance of this should be explained. A complete rationale should be provided for any opinions reached. If the examiner cannot provide some or all of such opinions, the examiner must make clear that he or she has considered all relevant, procurable data, but that any member of the medical community at large could not provide such an opinion without resorting to speculation. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Morford, 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.