Citation Nr: 21000879 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 16-12 670 DATE: January 6, 2021 ORDER Entitlement to service connection for migraine headaches is granted. REMANDED Entitlement to service connection for a gastroesophageal disease (GERD) is remanded. Entitlement to service connection for upper back and cervical spine disability is remanded. Entitlement to service connection for sinusitis and rhinitis is remanded. FINDING OF FACT The Veteran’s migraine headaches began during active military service. CONCLUSION OF LAW The criteria for service connection for migraine headaches have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty from January 1993 to January 1997. The Veteran appealed the February 2014 rating decision to the Board. This case was previously before the Board in December 2019. At that time, the Board reopened the issue of entitlement to service connection for gastrointestinal disorder (GERD). The Board remanded the issues of entitlement to service connection for GERD, on the merits, entitlement to service connection for upper back and cervical spine disability, and entitlement to service connection for sinusitis and rhinitis for further development. 1. Entitlement to service connection for migraine headaches The Veteran contends that his migraine disability began during service. The Board concludes that the Veteran has a current disability that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A February 2020 Headache Disability Benefits Questionnaire (DBQ) shows the Veteran has a current diagnosis of migraines. The record does not show treatment for headaches during service, but the Veteran reports that he experienced migraines during service and sought treatment. He testified that he was told to take some Tylenol and cover his eyes with a cold washcloth. He reported that he had one to two episodes a month while in service. In a July 1998 VA treatment record, just seven months after discharge from service, a physical therapist noted that the Veteran had symptoms suggestive of migraine headaches. The evidence against the claim includes a February 2020 VA opinion. The examiner opined that it was less likely than not that the Veteran’s migraines were related to service. The examiner noted that medical records do not show evidence of any clear etiology or likely etiology of migraines or headaches occurring during active service. The examiner noted that the Veteran’s entrance and discharge examination were not available to review in the claims file. A review of the record shows that the Veteran’s enlistment examination is included in the claims file. No migraine disability was noted on entry. The Veteran has reported that his migraine headaches began in service, and he is competent to report his symptoms during service. The Veteran’s former spouse testified that he had frequent headaches that caused him to lose his vision and that he had to confine himself to a dark room. See November 2018 statement. She did not include specifically when the migraine headaches began. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current migraine disability began in service. Although the examiner found the migraine disability unrelated to service, the examiner did not consider the lay statements submitted by the Veteran. The medical evidence shows that the Veteran was found to have symptoms within seven months after discharge, and the Veteran provided competent and credible statements that he had migraine headaches during service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a migraine disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a gastroesophageal disease (GERD) is remanded. The February 2020 examiner opined that it was less likely than not that the Veteran’s GERD disability was incurred in or was caused by the Veteran’s military service. The examiner noted that the medical records did not support GERD during active military duty. The Veteran testified that the Veteran suffered from epigastric discomfort during service, and on at least one occasion, vomited blood. The Veteran’s former spouse reported that he was admitted to Fort Eustis hospital in April 1993 due to vomiting blood. See September 2000 statement. An attempt should be made to obtain these records. The examiner also did not address this lay evidence. A remand is needed so that the examiner can address the Veteran and his former spouse’s statements regarding epigastric discomfort during service including vomiting blood during service. 2. Entitlement to service connection for upper back and cervical spine disability is remanded. The Veteran claims that his upper back and cervical spine disability is due to his military service. The Board remanded this issue in December 2019 and directed the examiner to opine whether the Veteran’s thoracic spine and cervical spine disability had its onset during service. The Veteran explained that the same incident that caused his service-connected lumbar spine disability during service, also caused his thoracic and cervical spine disability. The Veteran reported that he injured his back and neck when he had to perform drills with a 235 pound man on his back. He testified that although his lumbar spine was the focus in his service treatment records, he reported shooting pain up his back and into his neck during service. In February 2020, the Veteran was afforded an examination for his thoracolumbar spine. The examiner diagnosed the Veteran with lumbosacral strain only. An examination of the cervical spine was not obtained. Furthermore, the examiner provided an opinion about the thoracic spine and did not include an opinion about the cervical spine. In addition, an October 2006 MRI noted that the Veteran had an abnormality at C7 that was probably developmental. An opinion is needed as to whether the Veteran’s C7 developmental defect existed prior to service and, if so, whether it was not aggravated by service. For these reasons, a new examination and opinion is needed. See Stegall v. West, 11 Vet. App. 268 (1998). 3. Entitlement to service connection for sinusitis and rhinitis is remanded. The February 2020 examiner opined that it was less likely than not that the Veteran’s sinusitis or rhinitis was related to his military service. The examiner noted that rhinitis was likely caused by irritants or allergies while chronic sinusitis can be caused by deviated nasal septum or polyps. The examiner explained that the Veteran did report a history of head trauma during military service, but that the Veteran’s rhinitis or sinusitis is not trauma related. The examiner did not discuss the Veteran’s lay statements that his sinus issues began in June 1995 during active service. He explained that he suffered from upper respiratory infections and colds throughout service. Service treatment records corroborate that the Veteran was treated and diagnosed with upper respiratory infections and colds several times during his active service. An addendum opinion is needed that considers service treatment records showing upper respiratory infections and colds several times during service and whether this caused his rhinitis or sinusitis. The matters are REMANDED for the following action: 1. Obtain records of any inpatient treatment at Fort Eustis Hospital in April 1993. Document all requests for information as well as all responses in the claims file. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s gastroesophageal disease is at least as likely as not related to his reports of epigastric discomfort during service, to include on incident of vomiting blood. 3. Schedule the Veteran for a VA examination for his cervical and thoracic spine. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the cervical spine disability at least as likely as not related to service, including carrying a man on his back during training? Is the thoracic spine disability at least as likely as not related to service, including carrying a man on his back during training? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran’s description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? Did the Veteran’s cervical spine developmental disability clearly and unmistakably (undebatable) preexist the Veteran’s service? If the examiner finds it did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service? 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s sinusitis or rhinitis is at least as likely as not related to his military service, including being treated and diagnosed with upper respiratory infections and colds several times during service. See service treatment records. 5. Readjudicate the Veteran’s claims, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Tahirih S. Samadani, 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.