Citation Nr: 21068972 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 17-32 353 DATE: November 17, 2021 REMANDED Entitlement to service connection for dizziness is remanded. Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1977 to October 1981. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in July 2021. A transcript of the hearing is associated with the electronic claims file. 1. Entitlement to service connection for dizziness is remanded. 2. Entitlement to service connection for headaches is remanded. The Veteran initially requested service connection for posttraumatic stress disorder (PTSD), headaches, loss of hearing, memory loss, dizziness, and several other conditions in August 2010. At the time, the RO combined the Veteran's PTSD to include headaches and dizziness as symptoms of such. Accordingly, in a February 2012 rating decision, the RO only denied service connection for PTSD. The Veteran filed another application for service connection for hearing loss, depression, memory loss, alcoholism, rheumatoid arthritis, headaches, and PTSD in November 2014. The Veteran contended that his PTSD was the result of an assault in the Philippines while he was on active military service. The RO again combined the Veteran's complaints of headaches with his PTSD and issued an October 2015 rating decision denying service connection for PTSD. Following a notice of disagreement only with regard to PTSD, the Veteran was given a VA examination for such. Subsequently, the RO issued a November 2016 rating decision granting service connection for PTSD with major depressive disorder, moderate (also claimed as anxiety, nightmares, depression, difficulty falling asleep, flashbacks, memory problems, sleeplessness, drug and alcohol abuse), effective November 24, 2014, evaluated at 70 percent. Following this rating decision, the Veteran was given separate VA examinations for his complaints of dizziness and headaches in April 2017. The examiner found no ear or peripheral vestibular condition and instead noted that the Veteran "describes dizziness with headache. He states he has to sit down due to noise which brings on the dizziness." Finally, under remarks the examiner noted "No diagnosis of vertigo or dizziness within CPRS notes from VAMC facilities." With regard to his headaches, the examiner diagnosed vascular headaches dating back to 2009. The examiner then provided a summary of the Veteran's past treatment at VA for his headaches, including headaches following an auto accident, after being hit in the head, and a complaint for headaches and right chest pain in October 2003. The examiner opined that the Veteran's headaches with dizziness were less likely than not secondary to the assault in the Philippines. As rationale, the examiner provided "No evidence found regarding assault in Philippines, nor evidence of assault showing injury to Vet's head or neck. No STRs found regarding headache complaint (one STR note mentions HA during acute URI infection). One STR note 1981 found regarding 'fight' resulting in trauma to Vet's hand; no other specifics of incident...unknown date of claimed Philippine assault incident. Vet's hearing is WNL (most recent audiogram) and exam shows positive for tinnitus. No diagnosis of dizziness." Based on the examiner's opinions, the RO issued another rating decision in April 2017 adding dizziness and headaches as separate conditions and denying service connection. At the same time, a statement of the case denying service connection for dizziness and headaches was also issued. The Veteran appealed these issues to the Board contending that he did not feel like he was represented correctly by the April 2017 examiner, that she used incorrect information, and that the evidence was not properly reviewed because the denials came a day after his examination. In support of his claim, the Veteran submitted a statement in June 2021 wherein he again discussed his assault in the Philippines, however he wrote "my headache started progressing when I started working for the postal service. I kept a headache." He further explained that because of his PTSD and headaches he eventually had to resign as the noise, lights, and personnel increased his headaches. The Veteran then reported that while he was homeless, he was beaten again. At his Board hearing in July 2021, the Veteran testified that VA had diagnosed him with PTSD "and then as time progressed, I was having these headaches but they were not as frequent. But the last four years has been really tough. Each and every day." The Veteran also testified that his dizziness "comes whenever I am pretty much overexerting myself or I am around a lot of lighting, noise, concerts stuff like that." With regard to the assault in the Philippines, the Veteran testified that the incident occurred about a year into his service, that he did not report it, and that he served for another two years following the attack. He did not seek treatment for any conditions until he learned about VA around 2004. The Veteran's sister also provided a statement in support of his claim in May 2016 writing that the Veteran changed following his military service "became very argumentative, short tempered became dependent on drugs and alcohol. My brother became a different person right before my eyes." She also testified at his hearing again stating that the Veteran came back from the military as a different person "Headaches, short tempered. Would go off at the drop of a hat because of the pain." A review of the Veteran's service treatment records show that he was involved in a fight in March 1981, wherein he injured his right hand. No other problems were noted. At his separation examination in September 1981 no defects or diagnoses were found. Moreover, on his September 1981 report of medical history the Veteran did not indicate any problems with headaches or dizziness. The first available VA treatment records are from January 2003 with regard to an ulcer, wherein the physician noted "This patient should definitely stay on the Zantac/Mylanta that he is on and be given precautions: dizziness, red blood in stool, syncope or near, etc." The next records are from October 2003, when the Veteran presented with complaints of headaches and right chest pain on and off for about a month, but he left without an evaluation. VA records from May 2008 show the Veteran denying any headaches or dizziness and lightheadedness. However, in June 2009 there are notes stating "Came for stitches several months ago after being hit in the head, has had headaches since then. Headaches a couple of times a week." "hx head injury w/lacerations requiring sutures November 2008, now with chronic frequent headaches." Again, in May 2010 the Veteran complained of headaches and records from August 2010 note that the headaches are at the crown of the Veteran's head where he was hit a couple years prior. A record from November 2010 notes that the Veteran complained of "dizziness in the days." In October 2014 records note "Had auto accident about 3 weeks ago, daughter hit someone, and someone else hit him from behind. headaches worse since then. Lower back, leg. Hit head, got laceration to left eyebrow. Flashing light out of corner of left eye." Then in April 2015, the Veteran had an eye appointment due to the ongoing flashes after the most recent head trauma. The Veteran provided a letter in support of his claim from his social worker in March 2016, wherein she noted that even though the Veteran was engaging in his mental health sessions, when outside of sessions his symptoms are triggered. Specifically, she noted the Veteran "is fully aware of his triggers however, because of the challenges of managing his anger/anxiety his daily functioning is effected [sic] ie debilitating headaches, increased anxiety when in a group setting, and isolation from others." In light of additional relevant evidence added to the file since the April 2017 VA examinations, the Board will remand the issues to obtain updated VA examinations and opinions. The matters are REMANDED for the following action: 1. Update the electronic file with any new VA treatment records. 2. Afford the Veteran a VA examination for his claimed disorder manifested by dizziness. The Veteran's claims folder must be reviewed by the examiner. The examiner is asked to provide an opinion on the following question: (a.) In light of additional relevant evidence since the April 2017 VA examination report, is it at least as likely as not (50 percent probability or greater) that any disorder manifested by dizziness or any other ear or peripheral vestibular condition is etiologically related to the Veteran's active service, OR caused by OR aggravated by his service connected PTSD with major depressive disorder? In so opining, please consider and discuss the Veteran's June 2021 statement and his and his sister's testimony provided at the July 2021 Board hearing. A detailed rationale for the opinion must be provided. 3. Afford the Veteran a VA examination for his claimed disorder manifested by headaches. The Veteran's claims folder must be reviewed by the examiner. The examiner is asked to provide an opinion on the following question: (a.) In light of additional relevant evidence since the April 2017 VA examination report, is it at least as likely as not (50 percent probability or greater) that any headaches are etiologically related to the Veteran's active service, OR caused by OR aggravated by his service connected PTSD with major depressive disorder? In so opining, please consider and discuss the Veteran's June 2021 statement and his and his sister's testimony provided at the July 2021 Board hearing. A detailed rationale for the opinion must be provided. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Ruiz, 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.