Citation Nr: 21003807 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 17-24 474 DATE: January 22, 2021 REMANDED Entitlement to service connection for headaches, to include as secondary to service-connected conditions, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1968 to March 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision issued by the Department of Veterans’ Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Board previously remanded this matter in September 2020 for additional development. As will be discussed in more detail below, the Board finds substantial compliance with the September 2020 remand directives has not been met. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding when a remand is issued, the Veteran is entitled, as a matter of law, the right to compliance with the remanded order); see also D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding it is substantial compliance, not strict, with the terms of the remanded order that is required under Stegall). Entitlement to service connection for headaches, to include as secondary to service-connected conditions, is remanded. The Veteran contends his headaches were caused or incurred during service, or in the alternative, are secondary to his service-connected posttraumatic stress disorder (PTSD) or lumbar degenerative disc disease (DDD). The Board finds the evidence of record is not sufficient to resolve the Veteran’s claim. The Veteran was afforded a VA examination in November 2020 to determine the nature and etiology of his headache disability and its relation, if any, to service or to his service-connected conditions. Regarding aggravation, the examiner opined that the Veteran’s headaches are less likely than not aggravated by his service-connected PTSD or back condition. He reasoned that PTSD and DDD do not commonly aggravate migraines and there are no medical records that provide support to this claim. Contrarily, upon review, the Veteran’s treatment records indicate complaints of headaches following back pain. Thus, the VA examiner’s aggravation opinion regarding whether the Veteran’s DDD aggravates any headache condition is based on inaccurate information and remand is necessary for consideration of these treatment records. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding an opinion based upon an “inaccurate factual premise has no probative value). Additionally, during his VA examination for PTSD, the Veteran reported sleep problems stating that he wakes with headaches. He also stated in relation to this claim for PTSD that he experiences headaches when remembering events during service. The Veteran has multiple PTSD symptoms including but not limited to anxiety, nervousness, panic attacks, hypervigilance, and sleep problems. The VA examiner, however, failed to address whether the Veteran’s PTSD symptoms aggravate any headache condition. Rather, the VA examiner offered a causative opinion without consideration to the Veteran’s specific medical history and symptoms. See Cf. Polovick v. Shinseki, 23 Vet. App. 48 (2009) (finding an examiner’s opinion inadequate if not based on a Veteran’s specific medical history, risk factors, and military history). Thus, remand is necessary to obtain an addendum opinion addressing whether the Veteran’s headache condition is aggravated by his service-connected PTSD or DDD. The matters are REMANDED for the following action: 1. Return the entire claims file and this remand to the November 2020 VA examiner, if available, or to another appropriate examiner for review. The necessity of an in-person examination is left to the discretion of the examiner. The examiner shall provide an addendum opinion, including rationale, as to whether it is at least as likely as not (50 percent or greater probability) the Veteran’s headache condition is aggravated by his service-connected PTSD or lumbar degenerative disc disease. The examiner is specifically directed to address the Veteran’s lay statements regarding experiencing headaches following episodes of back pain as well as waking with headaches in relation to his PTSD sleep problems. The examiner is also directed to address the Veteran’s many PTSD symptoms. The VA examiner is cautioned that the term “aggravated,” as used in 38 C.F.R. § 3.310(b), does not require that there be “permanent worsening” of the nonservice-connected disability. Instead, secondary service connection is warranted for “any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence.” See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). The examiner must provide a complete rationale for any opinion expressed, based on the examiner’s clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. After the above development, and any other development deemed necessary, readjudicate the claim. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.C. Allen, 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.