Citation Nr: 21000856 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 19-35 867 DATE: January 6, 2021 REMANDED Service connection for headaches.   REASONS FOR REMAND The Veteran served on active duty from February 1955 to February 1957. The case is on appeal from a September 2016 rating decision. In a July 2020 decision, the Board remanded the claim of service connection for residuals of a head injury, to include headaches, for further development and adjudication. While the case was in remand status, in an October 2020 rating decision, the RO granted service connection for a traumatic brain injury (TBI) with a scar. Thus, the benefit is considered a full grant for TBI purposes. As noted, the Veteran’s initial claim of service connection included consideration of headaches as residuals of such head injury. The RO considered it as a still-pending separate claim of service connection also stemming from the TBI claim. TBI-related subjective neurological dysfunctions, such as headaches, might require a separate evaluation. See 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8045. The Board will further address this claim in the remand portion below. Service connection for headaches. The question for the Board is whether the Veteran’s headaches warrant a separate award of service connection as a separate and distinct disability or as a TBI-related neurological dysfunction pursuant to the provisions set forth in 38 C.F.R. § 4.124a, DC 8045. Pursuant to the Board’s July 2020 remand, the Veteran was afforded TBI and headaches VA examinations in October 2020. With respect to the headaches, the VA examination report contains a diagnosis of headache syndrome. The Veteran reported that the onset of his headaches was in 1955, some time after his head injury. The VA examiner indicated that per the Veteran’s history, the headaches “did not start at the time he reports he was hit in the head by a rifle at Fort Dix but began months after at Fort Sam Houston.” The examiner also noted that the Veteran has a scar on his left upper side scalp. In sum, the VA examiner concluded that while it is at least as likely as not that a TBI occurred in service as the left upper head scar, when considered along with his lay statements, confirm such in-service event, it is still less likely that the Veteran’s headaches are related to such injury as headaches “began some time after the head injury” when he was at Fort Sam Houston and that medical records do not support consistent, ongoing headache complaints. VA treatment records reflect that the Veteran has consistently reported a history of headaches ever since service. See August 3 and August 21, 2015 progress notes (complaints of headaches and migraines after being hit in the head with a rifle in the Army 60 years ago); December 1, 2015 (headaches from head injury in service); June 21, 2016 (headaches related to head injury; hit in the head by rifle); and April 10, 2018 (complains with headaches; has had it for 62 years diffuse; relieved by over the counter medication). The Board finds that the October 2020 VA opinion is not entirely sufficient to decide the Veteran’s claim at this time. First, the VA examiner indicated that the Veteran’s headaches are not related to his TBI as the Veteran’s headaches began “months after” the actual head injury. Nonetheless, while this might in fact rule out a link between the Veteran’s TBI and his headaches, the Board finds that the examiner’s rationale lacks a reasoned medical analysis or an explanation as to the medical basis on which the examiner relied his conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Moreover, it was based on the Veteran’s lay statements that the examiner acknowledged an in-service onset of headaches (while stationed at Fort Sam Houston); however, did not provide a nexus opinion considering a direct theory of service connection, particularly when he determined that while the headaches were not TBI-related, they had their onset during service. As noted above, throughout the pendency of this appeal the Veteran has consistently indicated that his headaches have been present ever since service and that he has managed it with over the counter medication. While the examiner deemed the Veteran’s lays statements credible for purposes of the in-service head injury, it appears that his lay statements as to the longstanding history of headaches ever since service were not considered in reaching his opinion. In light of the above, the Board finds that a remand is warranted for a VA examination and opinion by a neurology specialist for clarification in accordance with the reasons for remand set forth above and/or, alternatively, to provide a nexus opinion and comment on the nature and etiology of the Veteran’s claimed headaches. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination (or telehealth interview, records review, etc., if an in-person examination is not feasible) by a Neurologist in connection with the headaches claim. The physician should first identify whether the Veteran has any neurological condition, to include headache syndrome or migraine headaches, that is considered a residual of the reported in-service head injury. If not considered a residual, it should be explained why this is so. (i) For any identified headache disability, the examiner should then provide an opinion as to whether it is as likely as not (50 percent or greater probability) that the identified condition or disability had its onset during, or is otherwise related to, the Veteran’s reported in-service event. (ii) If no to (i), the examiner should then provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the identified headaches disability is a separate and distinct disability that had its onset during, or is otherwise related to the Veteran’s military service. Consideration should be given to: (1) VA treatment records acknowledging a longstanding history of headaches due to a head injury during military service; and (2) the Veteran’s lay statements as to the onset of his headaches and treatment with over the counter medication. A complete rationale or explanation should be provided for any opinions reached. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board William Pagan, 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.