Citation Nr: 21074685 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 15-29 225 DATE: December 16, 2021 REMANDED Entitlement to an initial rating in excess of 10 percent for a headache condition is remanded. REASONS FOR REMAND The Veteran served on active duty from August 2000 to June 2010. This case comes before the Board of Veterans' Appeals (Board) on appeal of a June 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a February 2018 videoconference hearing before the undersigned Veterans Law Judge. The issue on appeal was previously denied by the Board in November 2020. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2021 Order, pursuant to an August 2020 Joint Motion for Remand (JMR), the Court vacated the Board's November 2020 decision and remanded the claim for action consistent with the terms of the JMR. The case is now before the Board. In the September 2021 JMR, the Court found that the Board erred when it failed to provide an adequate statement of reasons or bases for its decision, as required by 38 U.S.C. § 7104(d)(1). The Court stated that because Diagnostic Code 8100 does not expressly contemplate the effects of pain medication, the Board may not deny entitlement to a higher rating on the basis of relief provided by Appellant's headache medication. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). The Court directed the Board to provide adequate reasons or bases that does not consider the effects of Appellant's medication. The last VA examination was conducted in July 2020. In that examination, the Veteran was using Aleve and Naproxen. The Veteran's VA records from April 2021 show the Veteran is also prescribed Amitriptyline, Sumatriptan, and began Alpha-Stim Aid for management of his headaches. The record simply does not offer findings which can establish the current nature and severity of this disorder and to what degree such findings would be obscured by the ameliorative effects of medication. Therefore, the record is insufficient for the Board to make a determination of a fair and appropriate disability evaluation. See McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). For the reasons stated, remand is necessary for a VA examination with current findings regarding the nature, extent, and severity of headaches, but which do not take into account the effects of medication or medications resulting in the easing of symptoms. The matter is REMANDED for the following action: 1. Contact the Veteran and/or his representative for information pertaining to any current treatment for headaches at any VA facility and by any private treatment provider. Obtain any records of the above treatments not yet associated with the claims file and associate them with the claims file. The assistance of the Veteran and/or his representative should be requested in obtaining any records of recent treatment as indicated. All attempts to obtain records should be documented in the claims file. 2. After all additional records have been obtained and associated with the claims file, but whether or not records are obtained, arrange for a VA examination for headaches by an examiner with an appropriate specialty for producing findings for headaches. The complete electronic claims file must be made available to the examiner in conjunction with the review. The examiner should detail all findings. The examiner is requested to provide a history, findings, and diagnoses as to the nature, extent, and severity of the Veteran's headaches, without consideration of any beneficial effects of medications. Any commentary or opinion rendered by the examiner must be accompanied by a rationale, by which conclusions are supported by references to and discussion of findings on examination, to clinical findings in the medical evidence of record and/or to accepted medical literature. The examiner is requested to comment on any relevant opinions found in the record. The Board urges the examiner to note that findings or opinions rendered without discussing such lay evidence of the Veteran and others will be deemed insufficient for VA adjudication purposes. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Hetman 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.