Citation Nr: 21014114 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 14-16 099 DATE: March 11, 2021 ORDER 1. Entitlement to service connection for imbalance is granted as part and parcel of the service-connected headaches. 2. Entitlement to service connection for concentration difficulties is granted as part and parcel of the service-connected headaches. 3. Entitlement to service connection for dizziness is granted as part and parcel of the service-connected headaches. FINDING OF FACT The evidence is at least in equipoise that the Veteran’s imbalance, concentration difficulties, and dizziness are part and parcel of the service-connected headaches. CONCLUSIONS OF LAW 1. The criteria for service connection for imbalance are met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303, 3.310 (2019). 2. The criteria for service connection for concentration difficulties are met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303, 3.310 (2019). 3. The criteria for service connection for dizziness are met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from November 1978 to November 1979. This case comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veteran Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in a November 2016 hearing. These issues were previously before the Board in June 2018, when they were denied. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (CAVC). In a December 2019 memorandum decision, CAVC vacated the June 2018 Board decision. These issues returned to the Board in June 2020 and were remanded for further development. That development was completed, and the case has since been returned to the Board for appellate review. The Board finds there was substantial compliance with the June 2020 Board remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The June 2020 Board remand instructed the RO to obtain and associate with the claims file any outstanding VA and private treatment records (PTRs), and to provide the Veteran with an appropriate VA examination. In June 2020, the RO sent a letter to the Veteran asking that he identify and authorize for release any outstanding PTRs. Later that month he submitted VA Form 21-4142 without identifying any medical providers. In July 2020, the Veteran again submitted VA Form 21-4142, this time only identifying VA Medical Centers (VAMCs). Additional VA treatment records were successfully added to the claims file in July 2020. The Veteran underwent VA examinations in July, October, and December 2020. Service Connection 1. Entitlement to service connection for imbalance 2. Entitlement to service connection for concentration difficulties 3. Entitlement to service connection for dizziness Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310 (2018); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In a November 2012 NOD, the Veteran stated that his dizziness, imbalance, and lack of concentration only occur when he gets headaches. In an April 2014 correspondence, the Veteran again reiterated that his dizziness was directly related to his service-connected migraine headaches, that he only experienced imbalance, and lack of concentration when he got migraine headaches. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). In a December 2020 VA medical opinions, the examiner noted that the Veteran does have a disability manifested by lack of concentration, dizziness, and instability, and that this disability is the already service-connected headache disability. Accordingly, the first element of service connection is met. Second, the Veteran is already service-connected for headaches. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.310. Accordingly, the second element of service connection is met. Third, the Board finds that the evidence of record shows that dizziness, concentration, and imbalance disabilities are related to the service-connected headaches. See 38 C.F.R. § 3.310. The Veteran underwent a VA medical examination in January 2012 where the examiner provided a negative nexus opinion. The examiner explained that the Veteran did not have a separate or distinct ear or peripheral vestibular condition. The examiner explained that migraineurs will often describe associated symptoms when they have headaches such as vision changes, nausea and vomiting, balance changes, and decreased concentration. The examiner stated that these symptoms are common and do not constitute a separate or distinct condition secondary to headaches. At the November 2016 Board hearing, the Veteran asserted that he never had dizziness, imbalance when walking, or lack of concentration unless he has a migraine. The Veteran stated that his physicians have noted that the imbalance and lack of concentration problem was connected to migraines. The Veteran also said that he had undergone neurological tests and been examined thoroughly, but that the doctors were not able to separate out the sub-symptoms of migraines, elaborate an alternate diagnosis, or to treat the symptoms separately. The Veteran also testified that he believed that if imbalance, along with other migraine associated symptoms are happening to his body, he believed that his current disability rating at 30 percent for service-connected headaches is kind of low. The Veteran underwent a headaches VA examination in July 2020 where reports he reported having headaches 3 to 5 times per week, and endorsed symptoms of nausea, vomiting, phonophobia, photophobia, spotty vision, imbalance, and dizziness. In October 2020, the RO obtained a VA neurological opinion. Based on a review of the records, the examiner provided a negative nexus opinion. The examiner noted that the Veteran was first diagnosed with migraine headaches in November 2013, an ischemic stroke in April 2018, and a left carotid stenosis in April 2018. The examiner stated that while the current neurological conditions could cause dizziness and imbalance, they developed over 30 years post-service. However, the Board notes that the Veteran has been service-connected for headaches with an effective date of November 1979. Also in October 2020, the Veteran underwent a VA psychological examination where the examiner provided a negative nexus opinion. The examiner explained that the Veteran reports his problems with concentration occur when he is having a headache, but not at any other time. The examiner noted that his concentration problems are considered to be a symptom of his headache condition, and that no separate diagnosis is warranted. In December 2020, the RO obtained VA medical opinions. Although they may appear to be conflicting opinions, the examiner opined that each of these disorders are part and parcel of the service-connected headaches. The examiner noted the evidence of a head injury in service, and the Veteran’s asserted symptoms of concentration, imbalance, and dizziness. The examiner explained that they seem to be associated with headaches, as other possible etiologies have been ruled out over the years by neurology, optometry, and mental health evaluations. Based on the current body of medical knowledge and evidence of record, the examiner opined that the symptoms are a manifestation of the already service-connected migraine headaches. The Board affords probative value to the positive December 2020 medical opinion because it reflects the most thorough review of the evidence of record, consideration of the Veteran’s assertions, and provided supporting rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Accordingly, service connection for imbalance, concentration difficulties, and imbalance are granted as part and parcel of the service-connected headaches disability. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Rogos 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.