Citation Nr: 21007442 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 14-42 858 DATE: FEBRUARY 9, 2021 ORDER Entitlement to service-connection for migraines, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is granted. FINDING OF FACT The Veteran’s service-connected PTSD and anxiety disorder symptoms aggravated his migraine headaches beyond their natural progression. CONCLUSION OF LAW The criteria for service connection for migraines, on a secondary basis, are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from September 1994 to October 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In December 2019 the Board remanded this claim for further development. The Board observes that the VA has adequately developed the Veteran's claim by, affording the Veteran with the necessary VA examination and a Supplemental Statement of the Case. Therefore, the Board finds that there has been substantial compliance with its prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Entitlement to service-connection for migraines, to include as secondary to service-connected PTSD The Veteran contends that his migraines were incurred in or aggravated by his service. In the alternative, he contends that his service-connected PTSD aggravated his migraines beyond the condition’s natural progression. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The service treatment records reflect the Veteran’s July 1993 pre-enlistment Report of Medical History in which he specifically denied ever having had frequent or severe headaches. There is no record of treatment for headaches in his 28 days of active service and the Veteran declined a separation examination after receiving a medical separation. VA treatment records include an August 2007 visit in which the Veteran pointed out worsening migraine headaches and a 2011 primary care consultation in which the Veteran reported that his headaches were relieved with Zomig and that he had received Imitrex from the emergency department. The Veteran described an unpredictable pattern of migraines that occurred as often as daily but that he generally had some sort of headache every week which involved his entire scalp throbbing and nausea. In September and October 2014, the Veteran’s VA neurologist discussed medications that had been unsuccessful in treating the Veteran’s migraine headaches and that he had underestimated the Veteran’s anxiety over Botox injections. The neurologist commented that the Veteran’s underlying mental illnesses of PTSD and his chronic anxiety made it more challenging to treat his migraines as his mental health disorders exacerbated the Veteran’s headache frequency. The Veteran testified at a Board hearing in April 2015 regarding his migraine headaches. His representative noted that the Veteran felt that his migraines were secondary to his PTSD and anxiety in that when he experienced a bad episode of PTSD and anxiety, he ended up with a migraine. His PTSD caused him a lot of insomnia which acts as a cycle. When he had anxiety and PTSD, he could not sleep and when he can’t sleep, he got headaches. The Veteran testified that he had always had headaches, but he didn’t experience true migraines until the PTSD symptoms started affecting his sleep. When he does not eat because of anxiety that can cause a headache. He testified that he was having migraines 3 to 5 times a week and that his neurologist was at his wit’s end and was trying Botox injections. The Veteran testified that he was provided 12 tablets of Zomig monthly, so he had to pick and choose when a headache if severe enough to take a Zomig tablet. His average migraine is three to four hours long and if he catches it early and can nip it in the bud with the Zomig, it will last 30 to 45 minutes. His childhood history of headaches was two or three a year when he was 10 to 12 years old. During a March 2017 physical therapy consult for worsening pain in the Veteran’s neck the Veteran acknowledged migraine headaches since he was young. Those headaches were not migraine headaches as migraines are distinct with sensitivity to light and noise and are much more debilitating than a standard headache. The Veteran stated that he really believed that his migraine headaches are deeply connected to his anxiety and PTSD. The Veteran underwent a VA examination for Migraine Headaches in January 2020. He reported initial treatment for headaches in 2001 after the headaches had been getting progressively more severe. The Veteran reported both tension-like headaches and migraine headaches 3 to 4 times a week lasting from hours to as long as 4 days with pulsating or throbbing pain on both sides of his head that was associated with nausea, changes in vision and sensitivity to light and sound, He was prescribed sumatriptan, ibuprofen and oxycodone as needed. His 2017 magnetic resonance imaging (MRI) scan revealed indications of migraines. The headaches produced pain productive of severe economic inadaptability. When the headaches flared-up he was required to rest in a dark room two to three times a week. After a review of the Veteran’s electronic claims file, an in-person examination and interview of the Veteran, the VA examiner concluded that the Veteran’s headaches were less likely than not incurred in or caused by an in-service injury, event or illness. As rationale, the examiner noted that during the Veteran’s month of service there was no evidence of headache or migraine complaints evident in the STRs. In addition, the examiner found that the Veteran’s headaches were less likely than not proximately due to or the result of the Veteran’s service-connected posttraumatic stress disorder (PTSD). The examiner explained that the causes of migraine are not fully understood. Both genetic and environmental factors appear to play a role. Imbalances in brain chemicals such as decreased serotonin and its interactions with the trigeminal nerve, lead to release of neuropeptides, which travels to meninges, and result in migraine pain. There is no authoritative medical research or evidence that supports PTSD as a cause of migraine headaches. Therefore, the Veteran's claimed migraines, are less likely than not proximately due to or the result of the Veteran's service-connected posttraumatic stress disorder. The examiner noted that he was unable to establish a baseline level of severity of the Veteran’s headaches which made it infeasible to determine whether the Veteran’s claimed migraine headaches were aggravated beyond its natural progression by the Veteran's service connected service connected posttraumatic stress disorder. He also noted that several factors may trigger migraines, including emotional stress, hormonal changes in women, food or food additives, alcohol, odors, changes in the wake-sleep pattern, sensory stimuli, physical exertion, changes in the environment, or medications. On the other hand, the examiner noted that PTSD is characterized by intrusive thoughts, nightmares and flashbacks of past traumatic events, avoidance of reminders of trauma, hypervigilance, and sleep disturbance. People with PTSD may experience panic attacks, with symptoms like agitation, dizziness, racing or pounding heart, and headaches. In this respect, the examiner stated that PTSD could be an emotional stressor that triggers the Veteran’s migraine headaches. The Board notes that the probative value of an examiner’s opinion is based on an accurate characterization of the evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). In January 2020 VA received buddy statements from the Veteran’s ex-wife, niece, wife, and friend. The Veteran’s ex-wife and mother of three of his children stated that prior to the Veteran’s military service, she recalled that the Veteran had 2 or 3 headaches a year that seemed to occur after he missed a meal. He did not take medication for the headaches. After service, his headaches were severe, brought tears to his eyes, caused him to see lights and sometimes lasted for days. His niece indicated that she lived with the Veteran for 3 years. During that period, he had 3 to 4 migraines a week despite taking his prescribed medications. The migraines typically started in the morning if they did not wake him from his sleep. The Veteran retreated to a darkened room while waiting for the headaches to subside. A friend and neighbor from 2015 to 2017 recalled occasions where the Veteran was unable to come to the telephone because of his migraines. The friend recalled the Veteran waking up around 9 am and having a headache that lasted until 3 pm when he stayed in the Veteran’s home for a period in 2017 while his own home was being repaired. The Veteran’s current wife stated that he has 3 to 5 migraine headaches a week since 2006 when they began living together. She described the headaches as severe, lasting from a few hours to a few days during which he was disabled from doing anything but laying down. Sometimes the migraines occurred after a nightmare or panic attack. She recalled one occasion when the Veteran lost vision in one eye and was rushed to the VA. In evaluating the probative value of competent medical evidence, the Court has stated in pertinent part the "[T]he probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the Court determined that the relevant inquiry is whether "the examiner providing the report or opinion is fully cognizant of the Veteran's past medical history." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). adjudicator..." See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds the Veteran's statements competent and credible. As noted above, a layperson is competent to describe the onset of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). The VA examiner indicated that he could not offer an opinion as to the baseline severity of the Veteran’s headaches which in turn precluded him from offering an opinion as to whether or not the Veterans’ migraine headaches were aggravated beyond normal progression by his PTSD and anxiety symptoms. The Board finds this explanation and opinion to be inadequate because the examiner identified emotional stress and changes in the sleep-wake pattern, factors that are apparent in the evidence of record, as triggers to migraines. The examiner failed to consider the Veteran's lay statements in his hearing testimony, lay statements of relatives and friends, and most importantly, the notes and opinion of his treating neurologist. See Dalton v. Nicholson, 21 Vet. App. 23 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board notes that a determination as to service connection is the responsibility of the finder of fact, not the examiner. The adjudicator is charged with interpreting the competent and credible evidence of record as a whole and reconciling such to accurately reflect the disability. Moore v. Shinseki, 555 F.3d 1369, 1373 (Fed. Cir. 2009); 38 C.F.R. § 4.2. While medical and lay opinions are evidence to be considered, the ultimate factual determination lies with the adjudicator. In this matter, there is a competent medical opinion expressed in the context of medical treatment while the VA examiner expressed his inability to render an opinion in terminology that offers the Board additional support for the opinion of the treating neurologist. While an adjudicator may not substitute his or her own opinion for medical judgment, a medical opinion cannot subvert the responsibility of the fact finder. Colvin v. Derwinski, 1 Vet. App. 171 (1991), see also Moore, supra. There is no competent lay or medical evidence that the Veteran’s migraines had their onset in or are otherwise attributable to service. However, the components of secondary service connection—a current disability, and evidence that the disability was caused or aggravated by a service-connected disability are satisfied by the Veteran’s PTSD and anxiety disorder. Therefore, the Board concludes that, with the benefit of the doubt resolved in the Veteran's favor, a grant of service connection for aggravation of the Veteran’s migraine headaches by his PTSD and anxiety disorder is warranted. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Adams Hill, 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.