Citation Nr: 21015632 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 15-01 024 DATE: March 18, 2021 REMANDED Entitlement to service connection for depression, to include as secondary to service-connected migraine headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1968 to January 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). When this matter was before the Board in May 2018, the Veteran’s claim for service connection for depression was reopened based on a finding that new and material evidence had been submitted. Entitlement to service connection for depression, to include as secondary to service-connected migraine headaches is remanded. This matter was last before the Board in May 2018, at which time it was remanded, in pertinent part, to obtain a VA examination and medical opinion. A VA medical opinion and addendum were obtained in February 2019 and April 2020, respectively. The Board finds that remand is warranted for an addendum medical opinion for the following reasons. In an October 2017 statement, the Veteran reported that he had severe migraines during service that caused depression due to chronic pain. He further reported that after service, his headaches severely worsened and were so debilitating that he became suicidal. Both the February 2019 and April 2020 examination and addendum found that the Veteran’s depression was not caused or aggravated by his service-connected migraine headaches. As rationale, the examiner stated only that the Veteran’s mental health condition was not severe enough to interfere with functioning and that the condition had improved. The examiner noted that the Veteran had not sought mental health treatment since 2013, had not been prescribed psychiatric medications since 2016, and had no psychiatric facility admissions. Notably, the opinion rendered does not specifically address the Veteran’s contentions with regard to his migraines and relies wholly on a lapse in the Veteran’s mental health treatment. The Board notes that medical opinion is insufficient if it is based solely on the absence of documentation in the record and does not consider the veteran's reports of symptoms and history. Dalton v. Nicholson, 21 Vet. App. 23 (2007). As such, an addendum opinion must be obtained on remand. Additionally, the Board notes that in the February 2019 and April 2020 examination and addendum, the examiner did not render separate opinions addressing causation and aggravation of the Veteran’s depression by his service-connected migraine headaches. For a secondary service connection claim, a VA medical opinion should address both causation and aggravation prongs; separate findings and rationales should be provided for each one. Atencio v. O'Rourke, 30 Vet. App. 74, 90 (2018). A remand is therefore necessary to obtain an addendum medical opinion for the Veteran's secondary service connection claim. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate clinician who has reviewed the claims file, to determine the nature, extent, and etiology of the Veteran’s depressive disorder. If another examination is deemed necessary, an examination should be provided. The examiner is asked to opine as to the following: Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s depressive disorder is either (1) caused or (2) aggravated (worsened beyond its natural progression) by his service-connected migraine headaches. The examiner must address the Veteran’s October 2017 statement wherein he reported that (1) he had severe migraines during service that caused depression due to chronic pain; and (2) that after service, his headaches severely worsened and were so debilitating that he became suicidal. The examiner is reminded that causation and aggravation are two separate inquiries, and separate findings and rationales should be provided for each one. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Marsh II, 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.