Citation Nr: 21071946 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 17-51 207 DATE: December 1, 2021 ORDER Entitlement to service connection for migraine headaches is granted. REMANDED Entitlement to service connection for gastroesophageal reflex disease (GERD) is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his migraine headaches are proximately due to and/or aggravated by his service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for service connection for migraine headaches as secondary to service-connected PTSD are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from August 1991 to August 1996. These matters come to the Board of Veterans' Appeals (the Board) from a March 2015 rating decision in which the Agency of Original Jurisdiction (AOJ) denied entitlement to service connection for migraine headaches and GERD, among other conditions. The Board previously remanded these claims in May 2019, as it concluded that they were inextricably intertwined with his claim for entitlement to service connection for an acquired psychiatric disorder to include PTSD, major depressive disorder (MDD), and anxiety. Following the Board's May 2019 remand, the AOJ granted entitlement to service connection for PTSD with MDD, anxiety, and alcohol abuse in an October 2019 rating decision. However, as it continued to deny service connection for migraine headaches and GERD, these issues have now returned to the Board for adjudication. 1. Entitlement to Service Connection for Migraine Headaches The Veteran contends that his migraine headaches are caused or aggravated by his service-connected PTSD with MDD, anxiety, and alcohol abuse. He adds that he has had migraine headaches since 1996 during his active military service. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 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). Service connection may also be granted for any injury or disease diagnosed after discharge when the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Additionally, service connection may be granted on a secondary basis for a disability that is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. A March 2019 note from the Veteran's private physician, Dr. S.E., demonstrates that the Veteran has a current diagnosis of episodic migraines. The Veteran's March 2015 and July 2020 Department of Veterans Affairs (VA) examinations also show that he has been diagnosed with migraine headaches. Thus, the first element of secondary service connection has been met. 38 C.F.R. § 3.310. The AOJ also granted service connection for PTSD with MDD, anxiety, and alcohol abuse in October 2019. The question for the Board is therefore whether the Veteran's migraine headaches are proximately due to or aggravated by his service-connected PTSD with MDD, anxiety, and alcohol abuse. The record contains conflicting medical opinions. Evidence in favor of the claim includes an April 2019 private medical opinion. G.G.U. opined that the Veteran's migraine headaches are at least as likely as not secondary to, related to, and/or aggravated by his service-connected PTSD with MDD, anxiety, and alcohol abuse. Her rationale was that medical literature suggests that PTSD causes a prolonged and elevated stress response, which "activates the HPA system, releasing abnormal levels of cortisol and adrenaline, thus causing a hypothalamic dysfunction and the development of headaches or, at the very least, contributing as an aggravating factor in the development" of migraine headaches. This examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran's most recent VA examination in July 2020 contained a negative etiological opinion. The examiner rationalized that the Veteran stated that his headaches began in 1999, while the March 2015 VA examination indicates that they began in 1996. As this was significantly before he was service connected for PTSD with MDD, anxiety, and alcohol abuse, the examiner concluded that it was less likely than not that the Veteran's migraine headaches are proximately due to or the result of his service-connected PTSD. The examiner also found no mention of headaches in the Veteran's psychiatric evaluations, thus indicating that it was unlikely that his PTSD caused worsening symptoms. However, this rationale fails to consider the Veteran's statement indicating that the frequency of his headaches increased since developing PTSD. Such weakens the overall the probative value of the July 2020 VA medical opinion. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's service-connected PTSD with MDD, anxiety, and alcohol abuse caused or aggravated his migraine headaches. Thus, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for migraine headaches is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to Service Connection for GERD The Veteran contends that he is entitled to service connection for GERD on a secondary basis because it is caused or aggravated by his service-connected PTSD with MDD, anxiety, and alcohol abuse. The Veteran underwent a VA examination to determine the nature and etiology of his current GERD diagnosis in July 2020. However, for the reasons to follow, the Veteran's claim must be remanded for a new medical opinion. When VA provides an examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). To be adequate, a medical examination report must contain clear conclusions, supporting data, and a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The examination should be based upon consideration of the Veteran's prior medical history and describe the disability and symptoms in sufficient detail to allow the Board to make a fully informed decision. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The July 2020 examiner opined that it is less likely than not that the Veteran's service-connected PTSD with MDD, anxiety, and alcohol abuse caused or aggravated his current GERD. His rationale was that the Veteran was not diagnosed with GERD until February 2019 and that it is unlikely that the Veteran's PTSD or related medications would cause GERD to onset six years later. However, as this opinion fails to consider the Veteran's lay statement indicating that his GERD symptoms began after developing PTSD, the examiner's opinion is insufficient. See Stefl, 21 Vet. App. at 123. Furthermore, the examiner found that there is no physiologic or evidentiary basis to think that the Veteran's GERD could be aggravated in just one year after his diagnosis. This opinion is conclusory and is therefore inadequate as well. See Nieves-Rodriguez, 22 Vet. App. at 301. The Veteran's representative also referenced medical literature suggesting a nexus between PTSD and GERD in his July 2019 brief. The examiner did not appear to consider this medical literature in rendering his opinion. Accordingly, the Veteran's claim must be remanded to obtain an addendum opinion that considers his lay statements regarding the onset of his symptoms and the medical literature indicating a potential relationship between PTSD and GERD. See Barr, 21 Vet. App. at 312. The matter is REMANDED for the following action: Obtain an addendum opinion to the July 2020 VA examination. The claims file must be made available to the examiner. Following review of the claims file, with any necessary examination and testing, the examiner should provide the following opinions: (a.) Is it at least as likely as not that the Veteran's GERD: i. Is proximately due to any of his service-connected disabilities, including his service-connected PTSD with MDD, anxiety, and alcohol abuse; or ii. Underwent any incremental increase in disability or any additional impairment of earning capacity, regardless of its permanence, due to any of his service-connected disabilities, including his service-connected PTSD with MDD, anxiety, and alcohol abuse? The examiner must consider (1) the Veteran's July 2019 statement indicating that he began experiencing GERD symptoms after the onset of his PTSD and (2) the medical literature referenced by the Veteran's representative in his July 2019 brief. Provide a rationale for all opinions proffered. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R.M. Sachs, 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.