Citation Nr: 21066810 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 16-13 987 DATE: November 2, 2021 ORDER Entitlement to service connection for migraines is granted. REMANDED Entitlement to service connection for Ehlers-Danlos syndrome with joint hypermobility syndrome is remanded. Entitlement to service connection for a bilateral knee disability is remanded. Entitlement to service connection for chronic nerve pain is remanded. Entitlement to service connection for an all-joint degenerative condition is remanded. Entitlement to service connection for a muscle degenerative condition is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for an eating disorder is remanded. FINDING OF FACT The Veteran's migraine headache condition was not caused by or incurred during her active service and was not caused by any service-connected disability. However, giving the Veteran the benefit of every reasonable doubt, her diagnosed migraine headache condition has been aggravated by her service-connected disabilities, including autonomic dysfunction with hyper adrenergic postural orthostatic tachycardia syndrome (POTS). CONCLUSION OF LAW The criteria for entitlement to direct service connection and for secondary service connection based on causation for a migraine headache condition have not been met. However, the criteria for entitlement to service connection for a migraine headache condition as aggravated by service-connected disabilities have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1985 through April 1986 and from May 1988 through May 1989. The Veteran presented sworn testimony before the undersigned Veterans Law Judge during February 2019 and December 2020 Board hearings. The claims file contains transcripts of the hearings. In a June 2019 Board Decision, the Board remanded to the Department of Veterans Affairs (VA) Regional Office (RO) for further evidentiary development and readjudication claims of entitlement to service connection for a bilateral knee disability, an all-joint degenerative condition, migraines, fibromyalgia, a muscle degenerative condition, a chronic nerve pain condition, and an eating disorder. Because additional evidence that is relevant to these claims has been added to the claims file since the most recent, April 2020 Supplemental Statement of the Case (SSOC) addressing those claims, and the Veteran did not respond to the notice letter informing her of her right to waive consideration of that evidence by the agency of original jurisdiction (AOJ), the Board must remand the matter to the AOJ for readjudication. See 38 C.F.R. § 20.1305(c); July 2021 Board Letter (notifying the Veteran of the new evidence and informing her that if she did not waive AOJ consideration of the evidence within forty-five (45) days, the Board would remand the matter to the AOJ pursuant to applicable law). While the evidence is pertinent to the Veteran's migraine headache claim (as discussed below) and has not yet considered by the AOJ in the context of that claim, the claim of entitlement to service connection for a migraines may be granted on the current record. Therefore, the Board may proceed to the merits of the migraine claim. See 38 C.F.R. § 20.1305(c). In the June 2019 decision, the Board also noted that the Veteran had a pending appeal with respect to her claim of entitlement to service connection for Ehlers-Danlos syndrome with joint hypermobility syndrome and that the claims of entitlement to service connection for a bilateral knee disability and an all-joint degenerative condition were inextricably intertwined with the Ehlers-Danlos claim. Because, for reasons discussed below, the Board finds that further development of the Ehlers-Danlos syndrome claim is required, the bilateral knee and all-joint degenerative condition claims must also be remanded. Further, as discussed below, the fibromyalgia claim is also inextricably intertwined with the Ehlers-Danlos syndrome claim. 1. Entitlement to service connection for migraines The Veteran contends that she first developed migraine headaches during her military service. See December 2020 Board Hearing Tr. at 21 ("the migraines were first diagnosed in military without a doubt."); February 2019 Board Hearing Tr. at 8 ("And when I went back on active duty, literally within a month of going on active duty, I started showing signs and symptoms again. And that's when... I had my first migraine."). Alternatively, she contends that her migraines have been aggravated by her service-connected autonomic dysfunction with hyper adrenergic POTS. See December 2020 Board Hearing Tr. at 21 ("So, it's directly connected to my blood pressure, which is the POTS and it's up and down... And so, [the swings in blood pressure] creates headaches."). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The January 2020 VA examination, particularly in the context of treatment records and prior examinations, shows the Veteran has a current disability of migraine headaches. With respect to direct service connection, the VA examiner opined that the headaches the Veteran experienced during service were not "sufficient to support a diagnosis of migraines Has in active service." January 2020 VA Examiner's Opinion. The examiner opined that the symptom of "headache" is not specific and is common in other conditions, including acute conditions. The examiner opined that the headaches during active service were not diagnosable as a migraine headache condition during service and are otherwise unrelated to the current migraine headache condition. The examiner referred to the February 2016 VA examination for a further rationale. The February 2016 VA examiner opined that the Veteran's did not have a current migraine headache disability which was related to her reports of frequent, severe headaches during her active service. In fact, the February 2016 VA examiner opined that the Veteran did not have a migraine headache condition. The February 2016 VA examiner's opinion is undermined by the disagreement with the January 2020 VA examiner's and September 2012 VA examiner's diagnoses of a migraine headache condition. The Board finds the January 2020 VA examiner's diagnosis of a migraine headache condition and the reason for diagnosing the condition more persuasive than the 2016 VA examiner's expressed reasons for not diagnosing a migraine headache condition. Because the Board rejects the underlying factual assumptions of the 2016 VA examiner's opinion (i.e., that the Veteran did not have a migraine headache condition), the 2016 VA examiner's opinion does not warrant any probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion obtains probative weight from "factually accurate, fully articulated, sound reasoning for the conclusion"); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) ("An opinion based upon an inaccurate factual premise has no probative value."). Nonetheless, the Board finds that the January 2020 VA examiner's opinion effectively incorporates the reasoning of the 2016 opinion with respect to the cause of her in-service headaches (pregnancy) and post-service headaches (multiple motor vehicle accidents, fibromyalgia, and TMJ) and the conclusion that the in-service headaches were not the initial manifestation of the post-service migraine headaches. Mozingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("even if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight...[I]f the opinion is merely lacking in detail, then it may be given some weight based upon the amount of information and analysis it contains."). The in-service headaches and post-service headaches had distinct causes and the post-service headaches are not etiologically related to active service, including because the cause of the in-service headaches was pregnancy and resolved during active service. This aspect of the opinion is entitled to probative value. Nieves-Rodriguez, 22 Vet. App. at 304. The September 2012 VA examiner similarly opined that the Veteran's post-service migraine headaches were related to post-service motor vehicle accidents and were not incurred in or otherwise related to her active service. The opinion adds further probative weight against the Veteran's claim. There is not probative, competent evidence in favor of finding that the current headaches are directly related to her active service. The various private opinion letters do discuss headaches in the context of the service-connected POTS, but do not relate the current migraine headache condition to the in-service manifestation of the autonomic dysfunction with hyper adrenergic POTS. Rather, as discussed below, they mention the symptom of headaches as a current manifestation of autonomic dysfunction with hyper adrenergic POTS and/or indicate that the current migraine headaches are aggravated by the current symptoms and physiological effects of the service-connected autonomic dysfunction with hyper adrenergic POTS. The Veteran's own opinion that the current migraine headache condition began during her active service as evidenced by in-service headaches is not competent evidence of the actual etiology of her headaches. As the 2020 VA examiner noted, the symptom of "headaches" may have many underlying causes, so headache pain during service would not necessarily have the same etiology as headache pain many years after service. The Veteran has not provided a rationale for her opinion beyond the similarity of the subjective symptoms. Determining the etiology of those headache symptoms, however, requires specialized medical education, training, and experience to determine the possible causes and to rule out unlikely causes. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran does not have any such education, training, or experience, and, as noted, has not provided a rationale for her lay opinion that accounts for the factors identified by the VA examiner. Her etiological opinion is not competent and is entitled to probative value. The greater weight of the evidence is against finding that the Veteran's current migraine headache condition was incurred in or is otherwise etiologically related to her active service. Although direct service connection is not warranted, the Veteran has alleged entitlement to service connection under a secondary theory. In the context of claims for secondary service connection, the evidence must demonstrate an etiological relationship between the service-connected disability or disabilities on the one hand and the condition said to be proximately due to the service-connected disability or disabilities on the other. Buckley v. West, 12 Vet. App. 76, 84 (1998). Secondary service connection may also be warranted for a nonservice-connected disability when that disability is aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Also, with regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused or aggravated by the service-connected disability. See Wallin v. West, 11 Vet. App. 509 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). With respect to whether the Veteran's service-connected disabilities caused her current migraine headache disability, the evidence is against the Veteran's claim. The January 2020 VA examiner opined that: "The migraine HA condition is not caused by the [service-connected] POTS." The examiner explained that, while the etiology of migraine headaches is not fully understood, they are a separate and distinct medical condition and referred to the February 2016 VA examination for a more robust opinion. As noted above, the February 2016 VA examiner's opinion is not entitled to probative value of its own as it is based on the finding that the Veteran does not have a current migraine headache disorder, but instead has episodic symptoms of headaches due to various causes. The examiner adopted the February 2016 VA examiner's reasoning that the current migraine headache condition was most likely directly caused by multiple post-service motor vehicle accidents that included a skull fracture. This aspect of the opinion is convincing and warrants probative value. Nieves-Rodriguez, 22 Vet. App. at 304. The claims file does not contain a competent, contrary opinion regarding the cause of the current migraine headache condition that outweighs the January 2020 VA examiner's opinion. Secondary service connection based on causation is not warranted. The January 2020 VA examiner also opined: "There is no aggravation of the migraine HA condition identified. The treatment records evident do not support aggravation of the migraine HA condition." This was the whole opinion and rationale. While the examiner listed medical literature after the opinion, the literature is not explained and, without some effort to relate the general principles enunciated in the literature to this aspect of the opinion and the specific circumstances of this case, the Board assigns it no probative value. See Sacks v. West, 11 Vet. App. 314, 316-17 (1998). The opinion otherwise fails to contain an adequate rationale for the finding that the service-connected POTS has not aggravated the current migraine headache condition, particularly in light of medical evidence and the Veteran's credible testimony that exacerbations of her service-connected autonomic disability trigger her headache condition. The Board assigns no probative value to the January 2020 VA examiner's opinion that the Veteran's service-connected disabilities do not aggravate her current migraine headache condition. The February 2016 VA examiner's opinion does not directly address aggravation, but contains some indication that the Veteran's various medical disabilities "trigger" her current migraine headache condition. The Board assigns some probative weight in favor of secondary service connection based on aggravation to this aspect of the 2016 VA examiner's opinion, particularly when the opinion is interpreted in the context of the entire record. Mozingo, 26 Vet. App. at 107. The January 2021 private opinion letter (by E.D., PT) also provides probative weight in favor of finding that the Veteran's service-connected disabilities aggravate the current migraine headache condition. Specifically, the private physical therapist noted: "Stress, anxiety, and muscle holding from coping with dysautonomia symptoms can contribute to systemic inflammation, and headaches." While the language used would be inadequate, standing on its own, to resolve this claim, see Bloom v. West, 12 Vet. App. 185, 187 (1999), the Board interprets it as having some probative value in the context of the entire record. Mozingo, 26 Vet. App. at 107. This evidentiary context includes the Veteran's own statements as well as other opinions of record. For example, the Veteran credibly testified that she has tracked her blood pressure and oximetry and noticed that spikes in her blood pressure are correlated with the onset of headaches. See December 2020 Board Hearing Tr. at 21. The December 2020 private opinion letter (by K.P., M.D.) specifically indicates that the service-connected POTS influences "blood pressure, joint inflammation/pain, as well as migraine." The July 2017 private opinion letter explains how her service-connected autonomic dysfunction with hyper adrenergic POTS affects her blood pressure (including increases and rapid decreases). In summary, there is substantial evidence in favor of finding that the Veteran's service-connected disability aggravates her migraine headache condition. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current migraine headache condition is aggravated beyond its natural progression by her service-connected autonomic dysfunction with hyper adrenergic POTS. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a migraine headache condition is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Because the only claim being addressed on the merits is granted, the Board will not discuss VA's compliance with the duties to notify and assist. REASONS FOR REMAND 1. Entitlement to service connection for Ehlers-Danlos syndrome with joint hypermobility syndrome is remanded. The record contains several opinions indicating that the Veteran has Ehlers-Danlos syndrome and, moreover, that her Ehlers-Danlos syndrome had onset in service or is otherwise related to her service-connected autonomic dysfunction with hyper adrenergic POTS. See January 2021 Private Opinion Letter (discussing link between Ehlers-Danlos syndrome and POTS); December 2020 Private Opinion Letter (same); September 2019 VA Examiner's Opinion (noting there may be a link between the Veteran's POTS and her Ehlers-Danlos syndrome, though indicating the EDS caused the POTS rather than the reverse); July 2017 Private Opinion Letter (same). The Veteran has not had a VA examination with respect to her Ehlers-Danlos syndrome and the record does not contain medical opinions directly addressing the medical questions that must be answered to resolve this claim. Importantly, the evidence of record suggests that Ehlers-Danlos syndrome may be a genetic condition or the complication of a genetic condition which predated her active service. Therefore, it is necessary to obtain opinions regarding whether the Ehlers-Danlos syndrome was a pre-existing condition and, if so, whether it was aggravated by her active service. Alternatively, there are suggestions that it first appeared as a diagnosable disease entity during active service. Finally, the record raises the possibility that the Ehlers-Danlos syndrome was either caused by or aggravated by her service-connected disabilities. Opinions on each of these questions is necessary to resolve the claim. Remand is required to obtain the necessary opinions. 2. Entitlement to service connection for a bilateral knee disability is remanded. 3. Entitlement to service connection for an all-joint degenerative condition is remanded. 4. Entitlement to service connection for fibromyalgia is remanded. The Board has previously determined that the bilateral knee and all-joint degenerative condition claims are inextricably intertwined with the Ehlers-Danlos syndrome claim. Moreover, the development since the last Board decision established that the Veteran does have fibromyalgia and the record suggests it may be related (causally or by aggravation) with the Ehlers-Danlos syndrome. The fibromyalgia claim is also inextricably intertwined with the Ehlers-Danlos syndrome. If the Ehlers-Danlos syndrome claim is granted, opinions should be obtained regarding whether the claimed bilateral knee disability, all-joint degenerative condition, and/or fibromyalgia are related to the Ehlers-Danlos syndrome. 5. Entitlement to service connection for chronic nerve pain is remanded. 6. Entitlement to service connection for a muscle degenerative condition is remanded. 7. Entitlement to service connection for an eating disorder is remanded. As discussed in the introduction, the record contains evidence not yet considered by the AOJ and the Veteran has not waived her right to have the AOJ readjudicate the pending claims after consideration of that additional evidence. Therefore, all the claims that cannot be granted must be remanded for this additional reason. See 38 C.F.R. § 20.1305(c). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from January 2020 to the Present 2. Ask the Veteran to complete a VA Form 21-4142 for any non-VA medical professionals or facilities which have provided medical treatment for any of the remanded conditions since January 2020, to include Dr. K.S.P (December 2020 opinion letter) and E.D., PT (January 2021 opinion letter). Make two requests for the authorized records from any identified facilities, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for a VA examination for her Ehlers-Danlos syndrome. 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: a. Did Veteran's Ehlers-Danlos syndrome clearly and unmistakably (undebatable) preexist the Veteran's service? b. If the examiner finds the Ehlers-Danlos syndrome did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service (i.e., if the Ehlers-Danlos syndrome increased in severity during service, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease)? c. If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not related to service, including her in-service pregnancy and physical exercise during active service. If the Ehlers-Danlos syndrome was not aggravated by service (i.e., the answer to (a) or (b) is negative) and is not directly related to service (i.e., the answer to (c) is negative), answer the following: d. Is Ehlers-Danlos syndrome at least as likely as not proximately due to her service-connected disabilities, particularly including autonomic dysfunction with hyper adrenergic POTS? e. Is Ehlers-Danlos syndrome at least as likely as not aggravated, i.e., worsened beyond its natural progression, by her service-connected disabilities, to include autonomic dysfunction with hyper adrenergic POTS? Provide a rationale to support the opinion(s). 4. Conduct any additional development that becomes necessary after obtaining the requested opinions with respect to Ehlers-Danlos syndrome, including obtaining any necessary opinions regarding whether any of the other claimed disabilities are related to the Ehlers-Danlos syndrome. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the issues of entitlement to service connection for (1) Ehlers-Danlos syndrome, (2) bilateral knee disabilities, (3) all-joint degenerative condition, (4) fibromyalgia, (5) chronic nerve pain, (6) a degenerative muscle condition, and (7) an eating disorder. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and her representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kerry Hubers 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.