Citation Nr: 21076777 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 16-59 409 DATE: December 27, 2021 ORDER Entitlement to service connection for headaches, to include as secondary to service-connected posttraumatic stress disorder with alcohol use disorder (PTSD), including medications prescribed for treatment thereof, is denied. FINDING OF FACT A chronic headache disability was not manifested in service, and the preponderance of the evidence is against a finding that his reported headaches represent a chronic headache disability that is etiologically related to his service or was caused or aggravated by his service-connected PTSD, to include medication prescribed for treatment thereof. CONCLUSION OF LAW Service connection for headaches is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from July 1986 to March 1991. This matter is before the Board on appeal from an August 2013 Department of Veterans Affairs (VA) rating decision. In March 2021, a videoconference Board hearing was held before the undersigned; a transcript is in the record. In July 2021, the matter was remanded for additional development. Entitlement to service connection for headaches, to include as secondary to PTSD, including medications prescribed for treatment thereof, is denied. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated in line of duty during active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disease first diagnosed after service may be service connected if all the evidence, including pertinent service records, establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, and any increase in severity due to the natural progress, from the current level. 38 C.F.R. § 3.310(b). The Veteran contends that his current headache disability was first manifested during service, or alternately, is secondary to his service-connected PTSD, to include as due to medication prescribed for treatment of PTSD. His STRs are silent for complaints, findings, treatment, or diagnosis of a headache disability. On March 1991 separation examination, neurologic clinical evaluation was normal; in a contemporaneous report of medical history, the Veteran denied history of frequent or severe headache. The postservice medical evidence in the claims file is silent regarding headaches until a June 2008 VA treatment record, which notes that the Veteran reported having daily morning headaches for 7 months; for which he did not take medication, even over-the-counter Tylenol. He reported he was told in the emergency room that he has obstructive sleep apnea (OSA), with non-refreshed sleep and daily morning headaches. The diagnoses included "suspect OSA which causes his morning [headache]." On July 2008 VA treatment, he reported that his headaches were not as frequent and his blood pressure has been down; the diagnoses included, in pertinent part, headaches. In later VA treatment records after that visit, "Headache" was included in the Veteran's active problem list. On September 2008 treatment, it was noted that Norvasc had been prescribed for treatment of the Veteran's hypertension for a couple of months, and his headaches had since gone away. Prinivil was then prescribed, and the headaches returned. On May 2009 treatment, the Veteran reported having headaches since he started taking blood pressure medication, which he took only intermittently. He reported having bad migraines upon waking in the morning. The provider instructed the Veteran regarding the importance of controlling his blood pressure and opined that leaving it uncontrolled was causing his headaches and chest pain. On June 2009 treatment, the Veteran's hypertension was noted to be a chronic problem, with symptoms including headaches, chest pain, palpitations, malaise/fatigue, blurred vision, dizziness, and shortness of breath. He reported he had headaches with occasional nausea, and that he used his CPAP machine only 2 to 3 times a week, and not for entire night, and that he was dizzy upon waking, with occasional blurred headaches. The provider instructed him to start using his CPAP machine daily, for the whole night, for 2 weeks to see if this changed his headaches, and opined that the headaches may be due to sleep apnea. On January 2010 treatment, the Veteran's uncontrolled blood pressure was noted to be a recurrent problem, and he reported having had some headaches and occasional chest pain, both considered to be symptoms associated with his hypertension. On August 2010 treatment, the assessments included in pertinent part benign hypertension, chest pain, and headache. The Veteran was encouraged to take his blood pressure medication; the provider opined that his chest pain and headache were from not taking the medication and resolved with restart of the medication. On April 2011 treatment, the Veteran reported having three to four headaches a week, usually lasting 20 minutes, and that he had shortness of breath with the headaches. He reported that this was a recurrent problem which was gradually worsening, and the current episode began more than one month prior. The assessments included headache and benign essential hypertension. He had not taken his blood pressure medications in six months. The provider opined that there was a component of depression in the Veteran's symptoms, noting that he was the sole provider in the household and was having problems with sexual desire and headaches. At the March 2021 Board hearing, the Veteran testified that he began having migraine headaches shortly after experiencing an explosion in the Gulf War, and that the headaches continued after service. He also testified that medication prescribed for treatment of PTSD, specifically Ambien prescribed in 2017, contributed to his headaches. On July 2021 VA examination, the Veteran reported experiencing migraine variants since 1989. He reported that the U.S.S. Roberts hit a mine in the Persian Gulf, and he was one of the sailors who had to board it and transfer bodies, some blown up and burned beyond recognition, to his ship, the U.S.S. San Jose. He reported that his headaches began approximately two weeks after seeing this. He reported tension headaches that occurred 6 times a month to the examiner, and indicated that he did not have a diagnosis of any type of headache. It was noted that he saw a psychiatrist for the incident that occurred prior to the headaches. Following a physical examination, the examiner determined that the Veteran did not have a diagnosis of a headache condition. The examiner opined that the claimed headache condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that there was no chronic diagnosis of migraine headaches; the Veteran did not describe symptoms of migraines, nor had he ever had a diagnosis of headaches of any kind; objective examination was normal, his symptoms were subjective only; and [an etiology] had not been established. The examiner further opined that the claimed headache condition is less likely than not proximately due to, the result of, or aggravated beyond its natural progression by the Veteran's service-connected disability. The examiner was unable to confirm a current chronic diagnosis with the current available records and/or the examination, and opined that therefore no nexus or plausible secondary relationship is established. It was noted that the Veteran reported he never received a diagnosis of migraine headaches and had never seen a neurologist for headaches. The examiner opined that the Veteran's description of headaches did not resemble signs or symptoms of migraines. The Veteran has established service connection for PTSD with alcohol use disorder. A chronic headache disability that is, a separate chronic headache disability entity, as opposed to headaches that are manifestations of an underlying disability is not shown to have been manifested in service or noted in postservice clinical records in the claims file prior to 2008. Accordingly, service connection for such disability on the basis that it became manifest in service and persisted is not warranted. It is not shown by the record that the Veteran's current claimed headaches are etiologically related directly to his active duty service. The earliest documented postservice clinical notation of complaints pertaining to headaches is in 2008, approximately 17 years after the Veteran's discharge from active duty. And as noted above, a VA examiner has opined that it is less likely than not that the claimed headaches were incurred during, or caused by, his military service, or caused or aggravated by his service-connected PTSD, explaining in essence that a diagnosis of a current chronic headache disability could not be confirmed based on the the current available records and examination [i.e., that headaches noted were manifestations of other underlying conditions, and not a separate disability entity]. Whether the Veteran's service-connected PTSD caused or aggravated a separate chronic headache disability (the diagnosis and etiology of a headache disorder) are medical questions beyond the scope of common knowledge and incapable of resolution by lay observation; they require medical expertise. The Veteran is a layperson; consequently, his own opinion is not competent evidence in this matter. See Jandreau, supra. He has not submitted a medical opinion (with rationale) in support of this claim (or identified any medical provider who has offered such opinion). The July 2021 VA examiner's opinion is the only medical opinion evidence in the record that addresses whether the Veteran has a headache disability, and if so its diagnosis. The opinion cites to clinical data in the record and to medical principles, and as noted above, it is probative evidence in this matter. The Board notes that in his hearing testimony the Veteran indicated he had onset of severe headaches in service, but notes further that he denied having headaches, or a history of headaches, on service separation. Regardless, continuity of a chronic headache disability postservice (which could potentially warrant a chronic disease presumption of service connection if found to be an organic disease of the nervous system under 38 U.S.C. § 1112) is not shown. The earliest postservice mention of headaches was in 2008. The Board further notes that the Veteran's complaints of headaches in the postservice evidence have been predominantly related by his treatment providers to his uncontrolled hypertension or his untreated sleep apnea, neither of which is service connected (are manifestations of an underlying disability [that is not service-connected] and not a separate disability entity). The providers' opinions are probative evidence in the matter. The Veteran has not presented competent evidence to the contrary (and has not alleged any specific deficiency in the opinions). His own opinion on the medical questions presented is not competent and probative evidence in the matter. Considering the foregoing, the preponderance of the evidence is against this claim. Therefore, the appeal in the matter must be denied. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechner, 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.