Citation Nr: 21073291 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 13-22 098 DATE: December 8, 2021 ORDER Service connection for migraines, as secondary to service-connected disabilities, is granted. FINDING OF FACT The Veteran's migraines are caused by her service-connected posttraumatic stress disorder with anxiety and depressive disorders (PTSD) and fibromyalgia. CONCLUSION OF LAW The criteria for service connection for migraines, as secondary to service-connected disabilities, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1981 to September 1992, with additional service in the Army Reserves. The case is on appeal from a November 2010 rating decision. In March 2016, the Veteran testified at a Board hearing. The case was most recently before the Board in July 2021, when the claim for service connection for headaches was remanded for a new medical opinion. Service connection for migraines. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis The Veteran contends that the headaches she experiences are related to service, either as a direct result of her active duty, or secondarily to a service-connected disability. At her March 2016 Board hearing, the Veteran testified that while she was in service, she was informed she had migraines. Additionally, in an August 2018 brief, the theory was raised of secondary service connection, to include whether medication to treat service-connected disabilities caused or aggravated the Veteran's headaches. The Veteran has expressed her belief that her headaches are a result of her psychiatric condition. In her November 2010 notice of disagreement (NOD), she stated that when she is reexperiencing a traumatic event as a symptom of her PTSD, she either suffers "from anxiety and panic attacks, including a migraine headache, or I become emotionally numb and disengaged." When asked whether she took time off due to mental health issues while at her July 2016 VA examination for PTSD, she stated, "I take time off because of bad headaches and because I don't sleep well at night due to dreams." In October 2016 correspondence, she indicated that anxiety attacks and headaches frequently happen together without warning. In July 2019 correspondence while discussing triggers for her PTSD, she described her response to the triggers as "I can actually feel the squeezing of my brain..." VA medical records also reflect her observing headaches in relation to her psychiatric disability. In a November 2016 medical CAPRI document, the Veteran requested long-term therapy for anxiety and panic attacks, and reported that she "endorsed the following accompanying symptoms: sweating, shortness of breath, headaches, and slurred speech" (emphasis added). In December 2017, the Veteran sought medical attention for her headaches that she felt had increased since starting medication. The Veteran was granted service connection for fibromyalgia on a presumptive basis in June 2018. At the Veteran's June 2018 examination for the condition, the examiner found that her current symptoms of the service-connected disorder included extreme joint stiffness, fatigue, and pulsating headaches. Thereafter in January 2020, the Veteran was granted service connection for her PTSD. Following a July 2021 Board remand for a new medical opinion by a neurologist for her headaches, the claims file was reviewed by a family medicine physician in August 2021. The examiner found a diagnosis of migraines, with symptoms of constant head pain, pain on both sides of the head, nausea, sensitivity to light and sound, and prostrating attacks. The examiner made a finding that the Veteran's headaches did not exist before service, nor occurred during service. The examiner opined that there is an association between headaches and psychiatric disorders such as PTSD; however, a causal relationship is not established. The examiner cited to a May 2011 article published by the National Center for Biotechnology Information (NCBI), a branch of the National Institutes of Health (NIH). The examiner then stated that headache disorders are multifactorial in nature, and given a lack of documentation or evidence showing the origin, he was unable to attribute a majority cause, and therefore the headaches are less likely than not due to fibromyalgia. In October 2021, an addendum opinion was obtained from the examiner. He opined that the headaches were not caused by, aggravated by, or part and parcel with PTSD as there is no known relationship, or fibromyalgia as there is insufficient supporting evidence. The examiner stated that he had reviewed the Veteran's lay statements, the November 2016 medical note of headaches that accompanied her anxiety and panic attacks, and the June 2018 VA examination finding of her headaches as a symptom of fibromyalgia, and that they support that an association may exist with psychiatric illnesses. He additionally wrote that the side effects of selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, for which the Veteran has been prescribed as recently as 2019, include headaches. However, his final opinion was that a causative relationship has not been established per the current literature, and referenced two additional articles published by the NCBI. The Board finds that the Veteran has a diagnosis of migraines, and it is a result of her service-connected PTSD and fibromyalgia. The June 2018 VA examiner found headaches as a symptom of her fibromyalgia, and the November 2016 medical provider listed headaches as an accompanying symptom of her PTSD. The Veteran is also competent to report the symptoms that she observes, to include headache pain while enduring anxiety and panic attacks. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Further, the VA examiner's August and October 2021 medical opinions acknowledged a relationship between headaches and PTSD, between headaches and use of SSRIs like her prescription for fluoxetine, and headaches and fibromyalgia. However, his overall determination was that there is no "majority" cause for headaches as the disorder is "multifactorial." The Board finds that these three, separate and acknowledged relationships provide sufficient evidence to determine that there is a nexus, or link, between her fibromyalgia and PTSD with medication, and they contribute to the cause of her migraines. In addition, the journal articles listed by the examiner as supporting evidence of his conclusion actually support the claim that the Veteran's PTSD can cause headaches. The May 2011 article titled "Post-Traumatic Stress Disorder and Migraine: Epidemiology, Sex Differences, and Potential Mechanisms" states that a growing body of literature supports an association between migraines and PTSD, and the presence of PTSD may increase this disability substantially. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974501/#R3. The February 2001 article "SSRI Antidepressant Medications: Adverse Effects and Tolerability," discusses that informed management by primary care physicians of the side effects of SSRIs, to include headaches, can assist in successful treatment of psychiatric conditions. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC181155/. Thus, when resolving reasonable doubt in the Veteran's favor, the Board finds that she currently has headaches that are related to her service-connected PTSD and fibromyalgia. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; Gilbert, 1 Vet. App. at 49. Accordingly, service connection is warranted for the Veteran's migraines, on a secondary basis to service-connected disabilities. The Board notes that the Veteran's symptoms of migraines may overlap the symptoms of other service-connected disabilities. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the Board determines that this is more akin to a downstream rating aspect of the claim that should be addressed in the first instance by the RO following implementation of the instant decision. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morford, 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.