Citation Nr: 21063742 Decision Date: 10/15/21 Archive Date: 10/15/21 DOCKET NO. 17-11 458 DATE: October 15, 2021 ORDER Entitlement to service connection for migraine headaches, to include as secondary to service connected sinusitis, is denied. REMANDED Coronary artery disease status post myocardial infarction, to include as secondary to service connected sinusitis, is remanded. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has migraine headaches due to an event, injury, or disease in service or secondary to a service-connected disability. CONCLUSION OF LAW The criteria for service connection for migraine headaches are not met. 38 U.S.C. § 1131; 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from April 1967 March 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision of the Saint Paul, MN, Department of Veterans Affairs (VA) Regional Office (RO). In October 2019, a Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. Service Connection 1. Entitlement to service connection for migraine headaches, to include as secondary to service connected sinusitis. The Veteran has asserted his headaches are either directly related to service or secondary to his service-connected sinusitis. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). After having considered all of the evidence of record, the Board concludes that the preponderance of the evidence is against finding that the Veteran suffers from migraine headaches related to his military service, to include as secondary to his sinusitis. The Veteran's service treatment records (STRs) are void for any indication of a headache related condition. In October 2014, the Veteran filed a claim for service connection for headaches as due to service. The Veteran underwent an examination in April 2015. He reported headaches since 1970 that have remained symptomatic since the initial onset. He reported severe headaches, with throbbing pain on both sides of the head that worsens with activity. He also experiences, nausea, light sensitivity, and visual changes during his migraines. His condition affects his ability to concentrate and causes sleep disturbances. He does not take any medication and is not otherwise engaged in treatment. The examiner concluded the Veteran's headaches are less likely than not related to his sinusitis. The examiner noted that there is such a thing as sinus headaches, which are related to sinuses. However, the examiner found in this case, the migraine headaches are a vascular condition, and the headaches are felt to arise from constricting and dilating arteries in the brain. The sinuses do not have an impact on arteries in the brain. At the Board hearing the Veteran reported experiencing headaches on a regular basis. He reported being told his headaches are caused by his sinusitis. In May 2020, the Veteran underwent another examination. He reported a long-standing history of headaches. The examiner noted there is no indication in the records of a diagnosis or treatment for migraine headaches outside of the examination from 2015. He was not undergoing any treatment for headaches. He reported temporal pain on either side of his head, with symptoms lasting between 1 and 2 days. The examiner opined the Veteran's headaches were less likely than not related to service. Upon separation from service, the Veteran denied any symptoms of headaches. The examiner opined the Veteran's headaches were less likely than not aggravated by the service connected sinusitis. The examiner noted there is no objective evidence of a significant and consistent aggravation of migraine headaches by sinusitis. The examiner also pointed to a single clinical note from 2016 indicating a headache accompanying an episode of acute sinusitis. Thus, the examiner found there is no indication of ongoing aggravation of the migraine headaches by sinusitis. The examiner noted prior to the filing for service connection in October 2014, there were multiple system reviews with no noted complaints of headaches. In a May 2021 addendum opinion, the examiner noted the Veteran's headaches were less likely than not related to service to include incurred in or caused by the fractured nose in service while playing basketball. The Veteran reported head and nose trauma to the face during service. Review of the records revealed on separation, he specifically indicated he did not suffer from frequent headaches. The examiner noted the first indication of headaches was not until 2015, over 45 years post separation from service, with no indication of any relationship to trauma or events during service. The examiner opined that the Veteran's headaches are less likely than not due to or the result of his sinusitis or deviated septum. The examiner noted the first indication of headaches was not until he filed a claim in October 2014. Prior to this date, there are multiple system review specifically noting no complaints of headaches. The examiner opined that the pathophysiology of migraine headaches is distinct from headaches related to sinus pathology or septal deviation. The examiner opined that the Veteran's migraine headaches were less likely than not aggravated by sinusitis or a traumatic deviated septum. The examiner further noted that review of the records revealed no objective evidence of a significant and consistent aggravation of headaches by sinusitis or septal deviation. The examiner also pointed to a single clinical note from 2016 indicating a headache accompanying an episode of acute sinusitis. The examiner found no indication of ongoing aggravation of migraine headaches by sinusitis. Again, the examiner noted that prior to 2014, there is no mention of headaches. The Veteran is in receipt of service connection for sinusitis, effective September 2011. The first mention of a headache condition was at the time of filing in 2014. The evidence shows no headaches within a year after separation from service. Although the Veteran believes he suffers from migraine headaches due to service, or secondary to sinusitis, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board affords more probative weight to the VA examiners' opinions. The 2020 examiner noted the only indication in the record of migraine headaches was the 2015 examiner's notation. The May 2020 examiner noted there was no evidence of aggravation of the Veteran's headaches by sinusitis. The May 2021 examiner noted there is no indication the Veteran's headaches are related to service, to include the fractured nose in service. On separation there was no indication of a headache condition, and again the first report of headaches was not until the time of filing in 2014. The pathophysiology of migraine headaches is distinct from headaches related to sinus pathology or septal deviation, and there is no objective evidence of a significant and consistent aggravation of headaches by sinusitis or septal deviation. In so concluding, the examiners provided a detailed rationaleincluding consideration of the medical evidence and lay reports. The examiners' opinions are probative, because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. There are no competent opinions to the contrary and in support of the Veteran's claims. The most probative evidence of record does not show that the Veteran suffers migraine headaches directly due to service or secondary to sinusitis. Therefore, the claim must be denied. REASONS FOR REMAND 2. Entitlement to service connection for coronary artery disease, to include as secondary to service connected sinusitis, is remanded. The Veteran was afforded an examination in May 2020. The examiner concluded the Veteran's CAD is less likely than not due to sinusitis, and noted there is no evidence of any direct, causal relationship between sinusitis and CAD. The examiner failed to provide adequate rationale for the conclusions reached, and did not address the contention of aggravation of his CAD by sinusitis. Accordingly, an opinion is needed to address the claim of secondary service connection. The matters are REMANDED for the following action: 1. Obtain an addendum opinion as to the Veteran's CAD. The need for an in-person examination is left to the discretion of the examiner. Following a review of the claim file, the examiner should provide an opinion for the following: a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's CAD is related to his service? b) Is it at least as likely as not that the Veteran's CAD was caused by a different disability, to include his service-connected sinusitis? c) Is it at least as likely as not that the Veteran's CAD was aggravated (worsened beyond the natural progression of the disease) by his service-connected sinusitis? The examiner is asked to consider the Veteran's contentions, personnel records, and STRs. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Skiouris, 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.