Citation Nr: 21065832 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 17-32 446 DATE: October 27, 2021 ORDER Entitlement to service connection for headaches, to include as secondary to service connected traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran had active air service from May 1988 to June 1988, October 1988 to February 1989, November 1990 to April 1991, April 1996 to August 1996, November 1997 to January 1998, and from May 1999 to August 1999. These matters come to the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision issued by the Department of Veterans Affairs (VA). This case was before the Board in March 2019 and October 2019, at which times the issue currently on appeal was remanded for additional development. The case has now been returned to the Board for further appellate action. In a November 2020 rating decision, the Veteran was granted entitlement to service connection for a traumatic brain injury (TBI), representing a full grant of the matter previously on appeal. Accordingly, that matter is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). The Board finds that additional information is required before the claim on appeal may be decided. In a January 2020 VA opinion, the examiner opined that the Veteran's headaches was less likely than not related to an in-service injury or event. In reaching this conclusion, the examiner commented that the Veteran currently followed up with neurology department for her ocular migraine headaches. The examiner noted that service treatment records showed multiple head concussions; however, extensive workup done in the past showed no clear neurologic etiology based on a prior workup that included computed tomography (CT) scan of the head and magnetic resonance imaging (MRI) scan of the brain that had been negative. The examiner indicated that the Veteran had multiple other medical comorbid conditions that could worsen her symptoms. The examiner also reported that the Veteran had a neurological diagnosis of ocular migraines that had an unclear etiology. When VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A VA medical examination is not inadequate merely because the medical examiner states he or she cannot reach a conclusion without resort to speculation. See Jones v. Shinseki, 23 Vet. App. 382, 391 (2010). However, a VA examination is considered inadequate where the examiner fails to articulate "a reasoned explanation" of her conclusion that no opinion is possible without resort to mere speculation. The Board finds that it is unable to decide the claim based on the findings contained within the January 2020 VA medical opinion report. In this regard, the Board is unable to interpret the opinion so as to adequately assess it as the examiner's opinion was essentially unresponsive to the question. The examiner's comments on the Veteran's headaches are not adequate to determine if it is related to service. To the extent that the examiner attempted to state that an etiology opinion could not be provided, the examiner's response did not comply with Jones v. Shinseki, supra. Therefore, a remand for an addendum opinion should be provided. The matter is REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records dated from November 2020 to the present. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, obtain an etiology opinion from an appropriate examiner to address the nature and etiology of the Veteran's headache. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail. Based on the review of the record, the examiner must provide an opinion as to the following: (A) Is it at least as likely as not (50 percent or better probability) that any currently present headaches, to include ocular migraine headaches, had its onset during his active service or is otherwise etiologically related to such service? (B) Is it at least as likely as not (50 percent or better probability) that any currently present headaches, to include ocular migraine headaches was caused or aggravated by her service connected TBI? The examiner should specifically discuss the medical treatise articles referenced by the Veteran's representative in a November 2019 submission. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page) The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician 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. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher O'Donnell, 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.