Citation Nr: 21008614 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 15-03 932 DATE: February 17, 2021 ORDER Entitlement to service connection for headaches (claimed as migraines) secondary to service-connected hypertension is denied. FINDING OF FACT The Veteran’s headaches are not proximately due to or aggravated by his service-connected hypertension. CONCLUSION OF LAW The criteria for entitlement to service connection for headaches (claimed as migraines) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1983 to November 1998 and from January 2003 to March 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2018 and July 2020, the Board remanded the issue on appeal for further development. There has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection 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 military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. To establish entitlement to service connection on a secondary basis, there must be competent medical evidence of record establishing that a current disability is proximately due to or the result of a service-connected disability. See Lathan v. Brown, 7 Vet. App. 359, 365 (1995). Further, a disability that is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). Entitlement to service connection for headaches (claimed as migraines) is denied. The Veteran contends in a July 2012 correspondence that his migraine headaches are due to his poorly controlled service-connected hypertension. Specifically, he reports that he has had difficulty controlling his blood pressure for many years and gets headaches when it is high. Consistent with the Veteran’s assertions, his service treatment records do not reflect a diagnosis of migraine headaches and there is no competent evidence suggesting the current tension headache disability onset in service or is otherwise related to service. Because the Veteran has not raised, and the record does not reasonably raise, a basis for direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or is aggravated beyond its natural progress by service-connected hypertension. The Board concludes that, while the Veteran has a current disability of tension headaches, the preponderance of the evidence is against finding that the Veteran’s tension headache is proximately due to or the result of, or aggravated beyond its natural progression by his service-connected hypertension. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Historically, the Veteran underwent a VA examination in November 2013 and was diagnosed with migraines. The examiner opined that the Veteran’s migraines were less likely than not proximately due to his service-connected hypertension because “these are distinct and separate entities.” As the examiner’s opinion was conclusory; did not offer a rationale; and did not address whether the Veteran’s service-connected hypertension aggravated his migraine beyond its natural progression, the issue was remanded in July 2018 for an addendum opinion. Pursuant to the Board remand, the Veteran underwent a new VA examination in June 2019. There, the Veteran was diagnosed with tension headaches. In amending the Veteran’s diagnosis from migraines to tension headaches, the examiner explained that the Veteran did not suffer from migraine headaches. Instead, the Veteran’s symptoms were consistent with tension type headaches (TTH). The examiner explained that based on physical examination and the Veteran’s history of symptoms, the Veteran suffered from TTH, which presents as bilateral mild to moderate pain of pressing or tightening quality, contrasting a migraine headache, which has unilateral pulsating pain. The examiner opined that the Veteran’s tension headache was less likely than not, incurred in or caused by the claimed in-service injury, event, or illness. The examiner also opined that the tension headaches are less likely than not proximately due to his service-connected hypertension or aggravated by his service-connected hypertension. The rationale was that tension headaches were the result of stress, lack of sleep, anxiety, depression, diet, and not eating on time. In July 2020, the Board remanded the Veteran’s claim for an addendum opinion. It appears the June 2019 VA opinions regarding ‘proximate cause’ and ‘aggravation’ may have been overlooked as multiple opinions were included on the examination report. Pursuant to the Board’s July 2020 remand, an additional VA medical opinion was provided in September 2020. In affirming the June 2019 VA examination report’s diagnosis of tension headaches, the VA examiner opined that the Veteran’s tension headaches were less likely than not proximately due to his service-connected hypertension. The examiner explained that tension headaches were due to dysfunction of the neuromuscular junction of the muscles of the head and neck, which was consistent with the July 2019 VA examiner’s opinion/explanation. The examiner further explained that migraine headaches were vascular in nature. The examiner referenced a medical article which considered “exceptions to the rule of hypertension not causing episodic headaches” and noted that none of the exceptions applied to the Veteran. The examiner furthered that “the current, widely accepted peer-reviewed literature does not support hypertension as a cause of chronic headaches, regardless of type.” The examiner also noted that while the Veteran was diagnosed with hypertension during service, his headache diagnosis was made at least a decade post-service and hypertension diagnosis. Thus, it was less likely than not that his tension headache was due to or incurred as a result of the hypertension (noting also that the opinion would remain unchanged for a diagnosis of migraines). The Board finds the June 2019 and September 2020 VA medical opinions probative because they are based on review of the Veteran’s medical history, medical literature, accepted medical knowledge and practice, and the examiners’ medical training and expertise. The opinions were also supported by cogent rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his headache disability is proximately due to, the result of, or aggravated beyond its natural progression by his service-connected hypertension, but he is not competent to provide a nexus opinion regarding this question. The issue is medically complex, as it requires knowledge and understanding of anatomical relationships and internal physiological processes and the interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The Board acknowledges the February 2015 medical treatise submitted in support of the Veteran’s claim by G.U., ARNP, MN, FNP, LNC. Generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive. Mattern v. West, 12 Vet. App. 222, 228 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). Medical treatise evidence may indicate enough of a basis of a generic relationship to establish “a plausible causality based on objective facts.” Mattern, 12 Vet. App. at 228 (citing Wallin v. West, 11 Vet. App. 509, 514 (1998)). In this case, the treatise evidence submitted is too general and inconclusive to establish causal nexus. Although G.U., ARNP, MN, FNP, LNC provided an excerpt from two studies that appear to discuss a possible relationship between migraines and certain types of hypertension, she did not discuss the treatise evidence at all or explain how it pertained to the unique circumstances of this particular Veteran. Most importantly, she did not provide a nexus opinion regarding the likelihood that the Veteran’s hypertension caused or aggravated his headache disability. This generic treatise evidence, when compared to the competent VA medical nexus opinions, is not found to be equally as persuasive. The June 2019 VA examiner reviewed that evidence and still determined that the Veteran’s service-connected hypertension neither caused nor aggravated his tension headache and provided cogent rationale in support of her opinion. (Continued on the next page)   In short, the competent and most probative nexus evidence fails to demonstrate a nexus exists between the Veteran’s tension headaches and his service-connected hypertension. Thus, the preponderance of the evidence is against service connection for tension headaches as secondary to hypertension. The benefit of the doubt doctrine is thus not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. For the foregoing reasons, service connection is denied. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Telamour, 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.