Citation Nr: 21076772 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 17-50 714 DATE: December 27, 2021 ORDER Entitlement to service connection for migraine headaches is granted. REMANDED Entitlement to service connection for an anxiety disorder is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. FINDING OF FACT The etiology of the Veteran's headache disorder is unexplained. CONCLUSION OF LAW The criteria for service connection for migraine headaches have been met. 38 U.S.C. §§ 1110, 1112, 1117, 1118, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 2007 to September 2010. This matter comes before the Board of Veterans' Appeals (Board) from an April 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for migraine headaches Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Generally, to prove service connection there must be: (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). Additionally, under legislation specific to Persian Gulf War veterans, service connection may be established for a qualifying chronic disability resulting from an undiagnosed illness that became manifest during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more no later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The term "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of any of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multi-symptom illness (MUCMI) that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under subsection (d) warrants presumptive service-connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). An illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Stewart v. Wilkie, 30 Vet. App. 383 (2018). The Veteran seeks service connection for migraine headaches, which he asserts is related to service. Specifically, the Veteran asserts that his migraine headaches began after he was involved in a motor vehicle accident during service. Alternatively, the Veteran contends that he suffers from migraine headaches related to his service in the Persian Gulf. As an initial matter, the Veteran's DD Form 214 confirms his service in the Southwest Asia theatre of operations during the Persian Gulf War. Therefore, he qualifies for consideration for presumptive service connection for disabilities resulting from an undiagnosed illness or medically unexplained chronic multi-symptom illness. In May 2013, the Veteran underwent a VA Gulf War examination. The examiner remarked that the Veteran's headache was of unknown etiology. Under Stewart, this means that the Veteran's headache disability is a MUCMI, and service connection is warranted. REASONS FOR REMAND 1. Entitlement to service connection for an anxiety disorder is remanded. 2. Entitlement to service connection for PTSD is remanded. The Veteran seeks service connection for an anxiety disorder and PTSD, which he asserts are due to in-service stressors related to fear of hostile military activity. The Board acknowledges that the Veteran served in an imminent danger pay area with service in Iraq, as indicated on his DD Form 214; however, the medical evidence of record contains conflicting mental health diagnoses and medical findings. The Veteran underwent a VA examination in April 2013, during which the examiner found the Veteran had a diagnosis of polysubstance dependence, but did not have a diagnosis of PTSD that meets the diagnostic criteria under the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The examiner explained that the Veteran's polysubstance dependence could lead to depression, but could also be the result of depressed mood and that his anxiety symptoms could be related to service in Iraq, fights during service, numerous psycho-social issues, or due to withdrawal from these substances. The Board notes that VA treatment records indicate that the Veteran has current diagnoses of PTSD, depression, and generalized anxiety disorder. In light of the above, the Board finds that a VA examination and medical opinion are warranted. The matters are REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. After records development is completed, schedule the Veteran for a VA PTSD examination to determine the nature of any psychiatric disorder and obtain an opinion as to whether such is related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be performed, and the results reported. After review of the claims file and examination of the Veteran, the examiner should identify all psychiatric disorders found on examination and respond to the following: (a.) If the Veteran is diagnosed with PTSD, the examiner should indicate the stressor(s) upon which the diagnosis is based, to include whether it is based on the fear of hostile military or terrorist activity. (b.) For each diagnosed psychiatric condition other than PTSD, state whether it is at least as likely as not (50 percent probability or greater) that the condition arose during service or is otherwise related to service, to include his service in an imminent danger pay area. A complete rationale for all opinions expressed should be provided. 3. If any of the claims remain denied, issue a supplemental statement of the case, as appropriate. Shamil Patel Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Lance, 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.