Citation Nr: 21077258
Decision Date: 12/29/21	Archive Date: 12/29/21

DOCKET NO. 09-10 944
DATE: December 29, 2021

REMANDED

Entitlement to a rating in excess of 10 percent prior to July 30, 2009; in excess of 30 percent from July 30, 2009, to March 17, 2015; and in excess of 50 percent on and after March 18, 2015, for migraine headaches is remanded.  

Entitlement to a total rating for compensation purposes based on individual unemployability due to service connected disabilities (TDIU) prior to March 18, 2015 is remanded.  

REASONS FOR REMAND

The Veteran had active service from September 1985 to September 1987.  

1. Entitlement to a rating in excess of 10 percent prior to July 30, 2009; in excess of 30 percent from July 30, 2009, to March 17, 2015; and in excess of 50 percent on and after March 18, 2015, for migraine headaches is remanded.   

The report of a December 2020 foot examination conducted for the Department of Veterans Affairs (VA) states that the Veteran experienced "a black out due to a migraine which contributed to him falling and injuring his face on 07/04/2020."  

VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive.  McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991).  The Veteran was last afforded a VA headache examination in June 2020.  In light of the possible increase in severity of the service connected migraine, further VA headache evaluation is needed.  

VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims.  Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992).   Clinical documentation dated after January 2021 is not of record.  

2. Entitlement to a TDIU prior to March 18, 2015.   

The issue of a TDIU prior to March 18, 2015, is inextricably intertwined with the issue being remanded and must also be remanded.  

The matters are REMANDED for the following action:

1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated him for the service connected migraine headaches.  Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile.  

2. Associate with the record any VA medical records not already of record, including for pertaining to treatment after January 2021.  

3. Schedule the Veteran for a VA headache examination conducted by a physician to assist in determining the nature and severity of the service connected migraine headaches.  The examiner must review the record and should note that review in the report.  A rationale for all opinions should be provided.  The examiner should provide a full description of the disability and report all signs and symptoms necessary.  The examiner should further specifically state whether the reported July 2020 "black out" was associated with service connected migraine headaches.  

 

 

J. T. HUTCHESON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	 A. Smith, 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.