Citation Nr: 21075615 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 18-23 002 DATE: December 21, 2021 ORDER Entitlement to service connection for migraine headaches is granted. REMANDED Entitlement to service connection for hypertension is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his migraine headaches are at least as likely as not related to active service. CONCLUSION OF LAW The criteria for service connection for migraine headaches are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1981 to July 1991. The Board remanded this case to the Agency of Original Jurisdiction (AOJ) in August 2021 for additional development. The case has now been returned to the Board for appellate action. 1. Service connection for migraine headaches The Veteran seeks service connection for headaches, which he asserts is related to service. The Board concludes that the Veteran has a current disability that began during active service and is related to active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). During his May 2020 Board hearing, the Veteran testified that his headaches began during service. He had been working on a light table for ten years, which caused him to develop headaches. The Veteran was prescribed low dose baby aspirin to treat his headaches; and he testified that he has continued to get headaches since service and has taken baby aspirin every day for the past 35 years. He believed that the daily aspirin prevented the throbbing type headaches that he had prior to being prescribed baby aspirin. In October 2021, the Veteran underwent a VA examination for headaches. His claims file was reviewed, and he was diagnosed with migraine headaches and tension headaches. He reported onset around 1982. The circumstances around onset of his headaches included exposure to a light table for 8-10 hours a day. His symptoms included vision problems, dizzy spells, imbalance, and head pain. The VA examiner noted that the issues of the Veteran's headaches is complex; however, he believed that the Veteran's headaches more likely than not had their origin during his service period. The examiner explained that multiple service treatment records documented headaches, including an October 1989 note of a 3-month headache with no noted trauma. Further, the Veteran's DD Form 214 indicated that he had been an imagery interpretation specialist, which seemed to confirm the Veteran's assertion that he had worked with a light table. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current migraine headaches are related to service. Accordingly, after resolving all 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 2. Service connection for hypertension is remanded Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure the Veteran is given every possible consideration. The August 2021 Board remand directed the AOJ to obtain the Veteran's complete service records, including treatment and personnel records. However, the claims file does not indicate if there was an attempt to procure other service treatment records or personnel records. During his May 2020 Board hearing, the Veteran stated that he did not believe that his complete service treatment records were in the claims file and that September 2021 VA examiner noted that he was not able to find evidence of nosebleeds during active service, although the Veteran stated that he was treated for nosebleeds during active service. Also, the examiner noted that he was unable to find blood pressure readings from June 1987 that mentioned in the service treatment records. Thus, a remand is required to ensure that all of the Veteran's service treatment records and personnel records are associated with his claims file. Further, the Board finds that the September 2021 VA medical opinion is inadequate as the examiner checked that the claimed condition is more likely than not related to active service and less likely than not related to active service. The Board cannot assume which one is meant to apply to hypertension. The rationale suggests that the opinion is meant to be negative, but a rationale based solely on the lack of evidence without further explanation is inadequate. The Board concludes that additional medical inquiry is warranted. The matters are REMANDED for the following action: 1. The AOJ should ensure that the Veteran's complete service records from his active duty service, including treatment and personnel records have been obtained. Document all attempts to obtain these records, if unable to obtain these records provide a memorandum explaining why the documents are unavailable. 2. Then, obtain a VA addendum opinion to ascertain the etiology of the Veteran's hypertension. The examiner should address whether it is at least as likely as not (50 percent or greater likelihood) that hypertension manifested during service, that hypertension was manifest to a compensable degree within one year of service, or that it is otherwise causally or etiologically related to a period of active duty service. In rendering the opinions, the examiner must consider and discuss the competent statements of the Veteran regarding the onset and continuity of the symptoms of his hypertension. Specifically, that the Veteran has had nosebleeds and increased stress since being diagnosed with hypertension. The examiner should consider and discuss the following: (a.) service treatment records which reflect that the Veteran underwent a coronary artery risk evaluation in July 1984 and July 1987; (b.) the June 1987 electrocardiographic record, which revealed sinus bradycardia; and (c.) the June 1987 service treatment record which reflects treatment for pain and edema of the Veteran's legs. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. If it is not possible to provide an opinion without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Costello, 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.