Citation Nr: 21008203 Decision Date: 02/12/21 Archive Date: 02/12/21 DOCKET NO. 12-14 444A DATE: February 12, 2021 ORDER Entitlement to service connection for migraines is denied. FINDING OF FACT 1. A migraine disability did not manifest in active service, was diagnosed more than one year after service, and was not caused by service-connected major depression disability. 2. As the baseline severity of the Veteran’s migraine disability cannot be established, the VA cannot concede that this disability is at least as likely as not aggravated by her service-connected major depression disability. CONCLUSION OF LAW The criteria for service connection, to include on a secondary basis, for migraines have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from May 1995 to September 1995. This appeal to the Board of Veterans’ Appeal arose from a September 2015 rating decision. In February 2018, the Veteran testified in support of her claim at a Board videoconference hearing. In July 2018 and July 2020, the Board, inter alia, remanded this service connection claim to the agency of jurisdiction (AOJ) for further development. After completing such actions, the Board is now satisfied that all notification and development actions needed to fairly adjudicate the claim on appeal have been accomplished, and will proceed with a decision. Service Connection The Veteran contends that she has a current migraine disability is related to her service. Alternatively, she asserted that her service-connected major depression disorder caused her current migraines. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for organic diseases of the nervous system if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309(a). The language of 38 C.F.R. § 4.124(a), Diagnostic Code 8100 categorizes migraines as an organic disease of the central nervous system. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disorder. 38 C.F.R. § 3.310(a). Secondary service connection may be found in certain instances in which a service-connected disability aggravates another condition. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-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. 38 C.F.R. § 3.310(b). Turning to the evidence of record, the Veteran’s service treatment records are unremarkable for any complaints or diagnoses related to migraines. The first documented complaints of migraines or headaches is seen during a February 2001 VA emergency room (ER) visit where she complained of stress-related headaches. As part of her June 2001VA psychiatric examination, the Veteran claimed that she developed headaches in 1999 principally limited to the bifrontal region. Several months prior, she reportedly started taking Celexa as prescribed by her psychiatrist, which she stated had markedly improved her headache. The examiner noted major depression under her Axis I diagnosis and severe headaches under her Axis III diagnosis. Later during an April 2009 VA ER visit, the Veteran complained of headaches, dizziness, insomnia, muscle pain, tingling sensation in the extremities and jaw, “burning” sensation in her eyes, blurred vision, and weakness. Since an ER visit earlier that month, the Veteran had discontinued all psychotropic medications related to her major depressive disorder, obsessive compulsive disorder, general anxiety disorder, and borderline personality disorder. Although the Veteran denied feelings of depression or anxiety, she had poor concentration, difficulty focusing, as well as decreased interest and energy. The attending resident made some adjustments to the Veteran’s prescriptions and encouraged her to resume therapy. The Veteran’s numerous SSA records, especially those from 2013, indicate that her migraines are attributed to her neck problems. In March 2014, during a VA psychiatric visit, the Veteran complained that work-related stress contributed to periods of anxiousness. During this time, she would feel really confused, scared, helpless and hopeless. Additionally, she would experience rapid heartbeats, tremors, and headaches. April 2014 medical records reflect the Veteran’s complaints of migraines alongside neck pain, suspected neuropathy, fibromyalgia, as well as other musculoskeletal disabilities affecting the spine and the right foot. Another January 2015 psychiatry note indicated an impression of recurrent moderate major depression and migraines. A December 2016 VA treatment record determined that her migraine headaches were worsening likely due to the emotional stress and anxiety related to her epigastric pain. During a May 2017 VA appointment, the Veteran reported that her migraine started in 1995 after her chronic neck pain. A VA neurologist indicated that the Veteran’s chronic migraines are a result of her medication overuse and neck pain (which was later found to be moderate-to-severe spondylosis). On September 2019 VA examination for her migraines, the VA examiner opined that the Veteran’s migraine was not aggravated by her service-connected major depressive disorder. As rationale, the examiner stated that depression or mental illness does not cause worsening of migraines headaches, which are a neurological disorder. The examiner further stated that there is no medical literature to support this. However, in the July 2020 remand, the Board found this opinion deficient because it did not address all theories of entitlement, lacked actual reasoning, and failed to discuss the medical evidence specific to the Veteran. Ongoing VA treatment records indicated that the Veteran was prescribed several medications for her headaches. The Board also notes a prescription for Ciprofloxacin, which lists blurred vision, headaches, and mood disorders as a side effect. During the Board February 2018 Board hearing, the Veteran stated that she has been suffered from migraines for at least ten years. At the moment, she was taking two separation medications that were not pain medications; one for sleep and one for her migraines specifically. Pursuant to the July 2020 Board remand, the AOJ obtained a September 2020 VA addendum opinion for the Veteran’s migraines. On the matter of direct service connection, the VA examiner opined that the Veteran’s migraines were less likely than not incurred in or caused by service. As rationale, the examiner stated that after review of the 6874-page e-file, he found no indication of chronic or recurrent migraines beginning in service and that the Veteran’s issues with headaches did not appear until after service. The examiner went on to state that a nexus could not be made due to the missing elements of origin and chronicity of the current condition dating back to service. The examiner went on to offer opinions on the basis of secondary service connection. On the matter of causation, the examiner stated that there is no evidence to suggest that the headache condition is due to any one particular cause, namely the depression. The examiner went on to say that the vast majority of migraines are idiopathic with completely unexplained causes. The condition is occasionally vascular in nature, hormonal, emotional, genetic, medication-related, due to OSA or CPAP use, due to brain lesions/masses or many other causes. Further, the examiner saw no supportive documentation in the e-file or the evidence specifically noted above to support such a connection. Reports of the Celexa lowering her headaches meant nothing about the causation of the headaches as it was entirely possible the Celexa simply serves as an analgesic (pain relief medication). In the past, the patient and various providers theorized that the condition is due to her neck, her depression and anxiety. The examiner could not simply narrow the causal relationship to the Veteran’s depression and rule out all other potential causes of the condition. Further, the examiner could not attribute the headaches to any particular cause, specifically the depression, without objective evidence as it would be entirely speculative. On the matter of aggravation, the examiner was unable to determine a baseline for the subjective migraine headache complaints with or without the depression without completely speculating as there was no measurable way to establish such a level objectively. However, regardless of an established baseline, the examiner went on to state that it is at least as likely as not that the Veteran’s migraines are aggravated beyond its natural progression by her service-connected depression. As rationale, the examiner stated that although there is no evidence to suggest that the headaches condition is due to depression (or any other particular cause) as it can have many causes, stress and emotional distress can cause worsening migraines. Moreover, it is likely some aggravation of the headache condition can be due to major depression. Considering the pertinent evidence in light of the governing legal authority, the Board finds that service connection for migraines on either a direct or secondary basis is not warranted. First addressing the relationship between migraines and service, the Veteran claimed that her migraines began in 1999. However, as noted above, the Veteran's in-service medical records, to include her separation examination report, are unremarkable as to any complaint, finding, or diagnosis pertaining to any migraines. Also, following service, there is no evidence of complaints or treatment for migraines until 2001, which is six years after the Veteran’s separation from active service. Such is clearly beyond the one-year presumptive period to establish her migraines as a chronic service-connected disease. Further, the Board points out that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. (1992). Significantly, the September 2020 VA addendum opinion, the only competent opinion to address the medical relationship, if any, between the migraines diagnosed years after service and either the Veteran’s service or her service-connected major depression weighs against the claim. This opinion was based on review of the Veteran’s previous VA examination, full consideration of the Veteran's documented history and assertions, and supported by clearly-stated rationale. As such, the Board accepts this opinion as probative of the medical nexus questions. See, e.g., Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). While several VA providers have noted that the Veteran’s migraines are related to her depression, the Board reiterates that short conclusory statements with no reasoning or explanation are not probative on the matter of nexus. Neives-Rodriguez, 22 Vet. App. at 304. Further, there are other contrary VA and SSA notations that attribute the Veteran’s migraines to her neck pain, medication overuse, and epigastric pain. These various notations further support the September 2020 VA opinion provider’s conclusion; namely, that attributing the Veteran’s migraines to any particular cause, specifically her depression, would be entirely speculative due to the idiopathic nature of the condition. As for the positive opinion on the matter of aggravation, the Board still cannot award service connection on this basis. Specifically, VA cannot concede that the Veteran’s migraines were aggravated by her service-connected depression because the September 2020 examiner was unable to determine a baseline for the subjective migraine headache complaints (with or without the depression) without completely speculating as there was no measurable way to establish such a level objectively. See 38 C.F.R. § 3.310(b). As a lay person, the Veteran is certainly competent to report matters within her own personal knowledge, such as the occurrence of an injury, and symptoms experienced. See e.g., Layno v. Brown, 6 Vet. App. 465 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Here, however, to the extent the Veteran has asserted continuing migraines since 1995 (and alternatively, in 1999) in connection with the current claim for monetary benefits, the Board finds such assertion inconsistent with the documented medical evidence of record discussed above to include a separation examination report noting no headache complaints or diagnosis, and post-service records that do not document migraines as an active complaint until 2001, and, hence, not credible. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (a pecuniary interest may affect the credibility of a claimant's testimony). Notably, as indicated above, the VA examiner considered the Veteran's current assertions in this regard, and still rendered an opinion that weighs against the claim. Finally, to whatever extent that the Veteran asserts a medical nexus between her migraines, and either service or service-connected major depressive disability, the Board finds that such assertions do not provide persuasive support for the claim. Matters of medical etiology of disabilities generally are within the province of trained medical professionals. See Jones v. Brown, 7. Vet. App. 134, 137-38 (1994). Although lay persons are competent to provide opinions on some limited medical issues (see Kahana v. Shinseki, 24. Vet. App. 428, 435 (2011)), the etiology of the migraines here at issue is a complex medical matter that falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377, n.4 (providing that lay persons are competent to identify a broken leg, but not to diagnose cancer). As the Veteran is not shown to be other than a layperson without appropriate training and expertise, she is not competent to render a probative (i.e., persuasive) opinion on the complex medical matter upon with this claim turns. Id. Thus, in connection with this claim, lay assertions as to the etiology of the disability for which service connection is sought have no probative value. For all the foregoing reasons, the Board finds that the claim for service connection for migraine disability, to include as secondary to service-connected major depressive disability, must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim on both direct and secondary bases, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Spann, 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.