Citation Nr: 21012952 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 17-25 649 DATE: March 8, 2021 REMANDED Entitlement to service connection for tension headaches is remanded. REASONS FOR REMAND The Veteran had active service from November 2008 to September 2012. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a March 2019 videoconference hearing and a transcript of the hearing has been associated with the claims file. The Board denied the Veteran’s claim in an August 2019 decision, after which the Veteran appealed the matter to the United States Court of Appeals for Veterans Claims (Court), which resulted in a July 2020 Order granting the parties’ July 2020 Joint Motion for Partial Remand (JMPR). Therein, the parties agreed that remand is warranted to provide a VA examination or obtain a medical opinion. This deficiency is more fully addressed below. Entitlement to service connection for tension headaches is remanded. Within the July 2020 JMPR, the parties agreed that remand was warranted because the Board erred in its August 2019 decision when it failed to provide a VA examination or obtain a medical opinion. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therein, the Board found that while the evidence of record “documents several intermittent complaints of headaches, [it does not] document probative evidence of a chronic headache disability which is related to active service.” Despite this finding, however, the parties found the Board failed to adequately address whether a medical nexus opinion was needed to address a November 2013 VA Headaches Disability Benefits Questionnaire (DBQ), which documented a diagnosis of tension headaches, yet failed to provide a medical nexus opinion addressing any potential relationship between the diagnosed headaches condition and the Veteran’s military service. As to the third step of the McLendon analysis, the parties agree that the evidence of record shows that the low threshold of this third element has been met. Specifically, when considering the totality of the evidence, which includes the Veteran’s lay statements and the current medical evidence confirming a diagnosis of tension headaches with an initial date of diagnosis between 2010 and 2012, the parties agree that the Board erred when it failed to find that the Veteran’s diagnosed tension headaches may be associated with his military service. Accordingly, the Board will remand the claim to obtain an adequate VA medical opinion that addresses the relationship between the Veteran’s tension headaches and his active military service. The matters are REMANDED for the following action: Refer the claims file to a qualified VA examiner for a medical opinion regarding the Veteran’s claim of entitlement to service connection for tension headaches. The claims file and should be made available to and reviewed by the examiner in conjunction with the opinion. If the examiner believes that an in-person examination is warranted, then schedule the Veteran for a full VA headaches examination. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: • The Veteran had active service from November 2008 to September 2012. • In July 2013, the Veteran claimed service connection for headaches, which he reported first had their onset in 2009. See VBMS entry with document type, “VA 21-526 Veterans Application for Compensation or Pension,” receipt date 07/10/2013. • Service treatment records document that the Veteran presented without any head symptoms in March 2009 while seeking treatment for gross hematuria. See VBMS entry with document type, “STR,” receipt date 08/05/2014, on page 139. • In September 2010, the Veteran denied head symptoms while seeking treatment for chest pain. See VBMS entry with document type, “STR,” receipt date 08/05/2014, on page 125. • During a September 2012 private sleep study, he complained of sleep apnea symptoms and was assessed with sleep apnea, common migraine, and hypertrophy of nasal turbinates. See VBMS entry with document type, “Medical Treatment Record - Non-Government Facility,” receipt date 09/22/2017, on page 1. • A March 2013 Army National Guard enlistment examination documents normal relevant clinical evaluations of the Veteran’s head and neurologic system. See VBMS entry with document type, “Medical Treatment Record - Government Facility,” receipt date 05/05/2014, on page 6 (items 17 & 39). • A March 2013 Report of Medical History shows that the Veteran denied a history of frequent or severe headache. See VBMS entry with document type, “Medical Treatment Record - Government Facility,” receipt date 05/05/2014, on page 11 (item 15.b.). • In a separate March 2013 Medical Prescreen of Medical History Report, the Veteran denied a history of frequent or severe headaches causing loss of time from work or school or taking medication to prevent frequent or severe headaches. See VBMS entry with document type, “Medical Treatment Record - Government Facility,” receipt date 05/05/2014, on page 14 (item 2.a.11.). • A November 2013 VA Headaches DBQ documents that the Veteran reported he was diagnosed with tension headaches during active service from 2010 to 2012 and given Motrin for treatment. The VA examiner noted that the Veteran’s tension headaches were usually brought on by stress. See VBMS entry with document type, “C&P Exam,” receipt date 11/09/2013. • February 2014 post-service treatment records from a military facility document the Veteran’s report of a headache and rash on his face after eating French salad dressing. See VBMS entry with document type, “STR,” receipt date 08/05/2014, on page 68. • Within his September 2014 NOD, the Veteran reported intermittent tension headaches that affect his ability to work. See VBMS entry with document type, “NOD,” receipt date 09/03/2014. • In October 2015, the Veteran reported that he was in a car accident the day before and had a headache that went away with Aleve medication. In February 2017, the Veteran complained of a migraine headache but denied any associated symptoms. See VBMS entry with document type, “CAPRI,” receipt date 09/01/2017, on pages 57 & 11, respectively. • In March 2019, the Veteran testified that he was diagnosed with tension headaches during active service and that he was treated with over-the-counter pain medication. He also reported current headaches every month that were brought on by stress. See VBMS entry with document type, “Hearing Transcript,” receipt date 03/21/2019, on pages 5 & 6. • The examiner’s review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. Following a review of the claims file, including the relevant evidence discussed above, the VA examiner is asked to render an opinion as to whether it is as likely as not (a 50 percent probability or greater) that the Veteran’s tension headaches were incurred in or are otherwise related to his active service. Upon what facts and medical principles do you base the opinion? In rendering the requested opinion, the examiner is asked to consider and discuss the relevant lay and medical evidence of record, including but not limited to as listed above. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Chad Johnson, 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.