Citation Nr: 21021245 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 17-54 469 DATE: April 12, 2021 REMANDED Entitlement to service connection for migraines is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 2003 to July 2003. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In March 2021, the Veteran testified before the undersigned Veteran Law Judge (VLJ) via live video conference. A transcript of the hearing will be associated with the record. 1. Entitlement to service connection for migraines is remanded. The Veteran contends that service connection is warranted because her migraine headaches did not pre-exist service and began during active duty. See March 2021 Hearing Worksheet. A review of the Veteran’s service personnel records show that she was discharged during in-processing at Ft. Leonard Wood, MO after reporting for basic training and serving for 23 days on active duty. See DD Form 214; July 2003 Department of the Army Orders 203-0365. A review of the Veteran’s June 2003 enlistment examination shows that she reported frequent or severe headaches and dizziness and fainting spells. The Veteran elected not to undergo a separation examination. See July 2003 Medical Examination for Separation – Statement of Option. Service treatment records (STRs) show that the Veteran was seen in the Emergency Department four times at Ft. Leonard Wood in July 2003 for migraine headaches and was provided medication. See July 2003 STR. The Veteran was also seen for shortness of breath in July 2003 and was found to have Asthma. She reported that she can’t keep up with normal daily training activities despite use of metered dose inhaler and was recommended for a discharge. In January 2018, the Veteran submitted a note from a private doctor that records that the Veteran reported that the onset of her headaches was when she was 18 years old, while serving in the Army. See January 2018 Statement in Support of Claim. However, the Board observes that since the condition on appeal was noted on the Veteran’s enlistment examination, a medical opinion is needed to address etiology, including whether the condition clearly and unmistakably pre-existed service and clearly and unmistakably not aggravated by service. Accordingly, the matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination for her migraine headaches. The examiner must review the claims file, including a copy of this Remand. The examiner is asked to provide a response to the following: a. Direct service connection – Is the Veteran’s migraine condition at least as likely as not related to service? b. Chronic diseases under § 3.309(a) – Is it at least as likely as not that the Veteran’s migraine headaches (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? c. Rebutting presumption of soundness/aggravation – Did the Veteran’s migraine headaches clearly and unmistakably (undebatable) preexist the Veteran’s service? If the examiner finds it did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service (any increase in severity)? If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not otherwise related to service. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran’s description of her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of her current disability, this should be noted. Stated another way, do the Veteran’s reports about her symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? 2. Readjudicate the Veteran’s claim, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, she and her representative should be furnished a supplemental statement of the case (SSOC) and afforded an appropriate period of time within which to respond thereto. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Khan, 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.