Citation Nr: 21071885 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 17-14 555 DATE: December 1, 2021 ORDER Entitlement to service connection for trigeminal neuralgia, claimed as headaches, is denied. FINDING OF FACT The Veteran's trigeminal neuralgia was not noted in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; the disability is not otherwise etiologically related to an in-service injury or disease to include exposure to herbicide agents therein, and such was not caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for trigeminal neuralgia, claimed as headaches, have not been met. 38U.S.C. §§1110, 5107; 38C.F.R. §3.102, 3.303, 3.307, 3.309. 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1971 to May 1974, including service in Thailand. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), which, inter alia, denied service connection for trigeminal neuralgia, claimed as headaches. In January 2020, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This matter was previously before the Board in March 2020. At that time, the Board remanded the claim for further evidentiary development, to include an addendum medical opinion. This matter was most recently before the Board in May 2021. At that time, the Board again remanded the claim for further evidentiary development, to include an addendum medical opinion. Entitlement to service connection for trigeminal neuralgia, claimed as headaches, is denied. 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). Disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Service connection for certain chronic diseases, including an organic disease of the nervous system such as trigeminal neuralgia, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). If a veteran was exposed to an herbicide agent during active service and manifests one of the enumerated diseases under 38 C.F.R. § 3.309(e), not currently including trigeminal neuralgia, to a compensable degree after such service, such will be service connected even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Despite the presumptive regulations, a claimant may establish service connection based on exposure to Agent Orange with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that he developed a headache disability as a result of his presumed exposure to herbicide agents and/or service-connected disabilities, including posttraumatic stress disorder (PTSD), ischemic cardiomyopathy, and chronic obstructive pulmonary disease (COPD). As a preliminary matter, the Board observes that in a March 2020 Board decision, the Veteran was found to have been exposed to herbicides in Thailand. Service treatment records (STRs) are negative for complaints, observations, or treatment regarding trigeminal neuralgia or associated symptomatology. At the Veteran's April 1974 separation examination, his neurologic system was examined and determined to be normal. On his accompanying Report of Medical History, the Veteran denied having or ever having had frequent or severe headaches and indicated that he was in good health. The Veteran was afforded a VA examination in December 2014. The claims file was reviewed. The Veteran was diagnosed with trigeminal neuralgia. The Veteran reported that his headaches began in 1974. He was placed on Tegretol and Dilantin and was told that he was experiencing neuralgia of the fifth nerve. The medications helped. He described headaches as starting in the jaw or temple and going to his eye, which felt like it was being pulled out of its socket. These headaches last from three to four hours to all day. His jaw feels like a toothache. The VA examiner opined that it was less likely than not that such was incurred in or was otherwise causally related to the Veteran's active service because the examiner found no evidence of headaches or trigeminal neuralgia in the Veteran's service treatment records. At the January 2020 Board hearing, noted above, the Veteran testified that he began to experience headaches while in Thailand, but self-treated with over-the-counter medication and tried to hide them. He noted that, when he returned to the United States following his service in Thailand, he experienced breathing difficulties coupled with headaches. The Veteran's representative contended that the Veteran's headaches could be brought on or aggravated by symptoms of his service-connected PTSD. Pursuant to the Board's March 2020 remand instructions, a VA medical opinion was obtained in September 2020. After review of the Veteran's claims file, the examiner rendered a negative etiological opinion regarding the Veteran's trigeminal neuralgia. The examiner opined in pertinent part, No documentation found in str regarding trigeminal neuralgia, nor treatments for headaches nor neuralgia as reported by Veteran during Dec 2014 C&P exam. April 17, 1974 report of medical history: no documentation of trigeminal neuralgia nor symptoms associated with trigeminal neuralgia. April 17, 1974 report of medical examination: no documentation of diagnosis of trigeminal neuralgia. No documentation found to support diagnosis of trigeminal neuralgia proximal to military discharge. Dec 2014 C&P exam, Veteran reported headaches began while serving in Thailand. He did not seek medical attention, however, self treated. The term at least as likely as not does not mean within the realm of possibility, but rather, it means that the weight of evidence both for and against a conclusion is so evenly divided that it is as sound to find in favor of that conclusion as it is to find against it. As noted above, SMRs [service medical records] are silent for evaluation of or treatment for trigeminal neuralgia. There is no medical evidence to support that Veteran's trigeminal neuralgia was caused by military service. Regarding secondary causation, the examiner opined in pertinent part, No clinical scientific research studies using appropriate research methodologies, large sample size which could be generalized which established a cause-and-effect relationship between trigeminal neuralgia [and] PTSD, ischemic cardiomyopathy and/or COPD. "Trigeminal neuralgia (TN) is characterized by recurrent brief episodes of unilateral electric shock-like pains, abrupt in onset and termination, in the distribution of one or more divisions of the fifth cranial (trigeminal) nerve that typically are triggered by innocuous stimuli. Compression of the trigeminal nerve root is the main mechanism of TN, but brainstem lesions account for a small proportion of cases. Most cases of TN are caused by compression of the trigeminal nerve root. Demyelination of one or more of the trigeminal nerve nuclei may also be caused by multiple sclerosis, tumors located at the cerebellopontine angle, or other structural lesions of the brainstem." With regard to aggravation, the examiner concluded, Trigeminal neuralgia is usually caused by pressure on trigeminal nerve, causing it to malfunction. Triggers for aggravating trigeminal neuralgia include: shaving, eating, touching face, drinking, brushing teeth, tactile stimulation of facial trigger zones. Neither PTSD, ischemic cardiomyopathy nor COPD cause compression of trigeminal nerve that would result in aggravation of trigeminal neuralgia. An additional VA medical opinion was obtained in October 2020. After review of the Veteran's claims file, the examiner rendered a negative etiological opinion regarding the Veteran's trigeminal neuralgia. The examiner opined in pertinent part, No clinical scientific research studies using appropriate research methodologies, large sample size which could be generalized which established a cause-and-effect relationship between trigeminal neuralgia [and] Agent Orange exposure. Mayo Clinic article presented by Veteran does not document Agent Orange as being a cause of trigeminal neuralgia. Trigeminal neuralgia is not recognized as presumptive condition associated with Agent Orange exposure. There is no medical evidence to support that Veteran's trigeminal neuralgia was caused by Agent Orange exposure. Pursuant to the Board's May 2021 remand instructions, a medical opinion was obtained in July 2021. After review of the claims file, the examiner rendered a negative etiological opinion regarding the Veteran's trigeminal neuralgia. The examiner opined in pertinent part, April 17, 1974 report of medical exam physical exam normal. April 17, 1974 report of medical history no documentation of dx [diagnosis] trigeminal neuralgia, headaches, or face pain. No documentation found in STR nor records proximal to military discharge indicating complaint of, diagnosis of, nor treatment for trigeminal neuralgia. No documentation found in STR nor records proximal to military discharge regarding symptoms consistent with diagnosis of trigeminal neuralgia. No clinical scientific research studies using appropriate research methodologies, large sample size which could be generalized establishes a cause-and-effect relationship between trigeminal neuralgia and Agent Orange exposure. Regarding secondary service connection, the examiner opined, No clinical scientific research studies using appropriate research methodologies, large sample size which could be generalized establish a cause-and-effect relationship between ptsd, ischemic cardiomyopathy and/or copd and trigeminal neuralgia. "Trigeminal neuralgia (TN) is characterized by recurrent brief episodes of unilateral electric shock-like pains, abrupt in onset and termination, in the distribution of one or more divisions of the fifth cranial (trigeminal) nerve that typically are triggered by innocuous stimuli[.] Compression of the trigeminal nerve root is the main mechanism of TN, but brainstem lesions account for a small proportion of cases. Most cases of TN are caused by compression of the trigeminal nerve root[.] Demyelination of one or more of the trigeminal nerve nuclei may also be caused by multiple sclerosis, tumors located at the cerebellopontine angle, or other structural lesions of the brainstem." With regard to aggravation, the examiner concluded, Dec 2014 C&P provided documented symptoms consistent with and gave diagnosis of trigeminal neuralgia. No documentation found to support aggravation of trigeminal neuralgia, such as documentation of worsening symptoms, change in treatments for condition. No documentation found indicating Veteran has received treatment for trigeminal neuralgia. Triggers for aggravating trigeminal neuralgia include: shaving, eating, touching face, drinking, brushing teeth, tactile stimulation of facial trigger zones. Ptsd, ischemic cardiomyopathy nor copd are known to aggravate trigeminal neuralgia. Additionally, the examiner, inter alia, noted that the Veteran reported experiencing headaches coupled with breathing difficulties when he returned to the United States and complaints of continued symptoms since that time. The examiner indicated that trigeminal neuralgia did not present as headaches with breathing difficulty. After a review of the evidence, the Board finds that service connection is not warranted for trigeminal neuralgia. With regard to the first element of a service connection claim, the evidence shows that the Veteran has a current disability. The December 2014 VA examination noted a diagnosis of trigeminal neuralgia. In addressing the second element, as noted above, in a March 2020 Board decision, the Veteran was found to have been exposed to herbicides in Thailand. Therefore, to that extent, the second element of service connection has been met. With respect to the third element, the nexus requirement, the Board finds that the probative evidence is against a finding that the Veteran's trigeminal neuralgia is causally related to active service. The Board assigns great probative weight to the July 2021 VA medical opinion, as the examiner reviewed the Veteran's claims file in its entirety. After considering the record, the examiner concluded that the Veteran's trigeminal neuralgia was not causally related to active duty. The examiner provided a reasoned conclusion and clear rationale to support her determination that the Veteran's trigeminal neuralgia was not causally related to service. She considered the Veteran's reports of his in-service headaches and the continuity of symptomatology, but ultimately explained that the current pathology was inconsistent with an in-service incurrence, particularly in light of the lack of treatment in service and medical literature indicating that there was not a cause-and-effect relationship between trigeminal neuralgia and Agent Orange exposure. There is no medical opinion evidence to the contrary. The Board assigns less probative weight to the December 2014 VA examination, which was found to be inadequate in the March 2020 Board remand to the extent the opinion was conclusory in nature. The Board also assigns less probative weight to the September and October 2020 medical opinions, which were found to be inadequate in the May 2021 Board remand to the extent that the examiner failed to consider the Veteran's lay statements and hearing testimony regarding in-service headaches and continuity of symptomatology and conflated secondary causation with aggravation. Additionally, the Board assigns less probative weight to the Veteran's hearing testimony indicating that his trigeminal neuralgia was caused by active duty. Although the Veteran is competent to describe symptoms, he is not competent to determine the cause of his symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have had medical training or skills. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Questions of competency notwithstanding, the Board assigns more probative weight to the findings of the July 2021 VA examiner, given her clinical expertise and the rationale she provided. The Board also finds that service connection is not warranted on a secondary basis. In that regard, the Board assigns great probative weight to the July 2021 VA medical opinion, as the examiner reviewed the Veteran's claims file in its entirety. After considering the record, the examiner concluded that the Veteran's trigeminal neuralgia was not caused or aggravated by his service-connected PTSD, ischemic cardiomyopathy, or COPD. The examiner provided a reasoned conclusion and clear rationale to support her determination that the Veteran's trigeminal neuralgia was not secondarily related to or aggravated by his PTSD, ischemic cardiomyopathy, or COPD. There is no medical opinion evidence to the contrary. The Board assigns less probative weight to the December 2014 VA examination, as the examiner did not render an opinion regarding secondary service connection. The Board also assigns less probative weight to the September and October 2020 medical opinions, as well as the Veteran's hearing testimony indicating that his trigeminal neuralgia was secondary to his PTSD, ischemic cardiomyopathy, and/or COPD, for the reasons explained above. In reaching this decision, the Board has considered the fact that the Veteran has been diagnosed as having trigeminal neuralgia, an enumerated disease under 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, the disability was not shown as chronic in service, did not manifest to a compensable degree within the presumptive period, and was not noted in service with attributable continuity of symptomatology. As set forth above, the Veteran's service treatment records contain no indication of trigeminal neuralgia. Notably, at his April 1974 separation examination, his neurologic system was examined and determined to be normal, and the Veteran denied having or ever having had frequent or severe headaches. The post-service record on appeal shows that the Veteran was not diagnosed as having trigeminal neuralgia for decades after his separation from active service and well outside the applicable presumptive period. While the record contains the Veteran's recollections that he developed headaches during active duty which continued to the present, and he is certainly competent to report having experienced such symptoms, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of trigeminal neuralgia as the Veteran has not demonstrated the necessary medical expertise. Jandreau, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Based on the foregoing, as the probative evidence is against the Veteran's claim of service connection for trigeminal neuralgia, the benefit-of the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the elements of service connection are not met, and the Veteran's claim for trigeminal neuralgia is denied. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Ruddy, 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.