Citation Nr: 21021327 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 10-43 891 DATE: April 12, 2021 ORDER Entitlement to service connection to headaches on a secondary basis only, is denied. FINDING OF FACT Headaches are not caused or aggravated by the Veteran’s service-connected post-traumatic stress disorder, major depressive disorder, and panic disorder. CONCLUSION OF LAW The criteria for entitlement to service connection to headaches on a secondary basis only, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the Army from June 2006 to August 2008. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2010 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Waco, Texas. In October 2013 the Veteran presented testimony at a travel Board hearing before the undersigned Veterans Law Judge (VLJ). The January 2020 Board decision addressed direct service connection and service connection as a chronic disability. Accordingly, the Board’s adjudication will consider only entitlement to secondary service connection. This issue was previously before the Board in January 2020, March 2020, June 2020, and October 2020, when it was remanded for further development, that development was completed, and the case has since been returned to the Board for appellate review. Duties to Notify & Assist Neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Board also finds that there has been substantial compliance with the prior October 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The issue was remanded to address medical articles cited by the Veteran’s representative and VA treatment record. A VA examiner provided a November 2020 opinion and January 2021 clarification to adequate address the October 2020 remand directives. Accordingly, the Board will proceed with appellate review. Secondary service connection- headaches Service connection may 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). The question for the Board is whether the Veteran has headaches that are proximately due to or the result of or were aggravated beyond the natural progress by service- connected mental health disorders. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). An August 2018 VA examination diagnosed migraine headaches and resolved tension headaches. Accordingly, the first element of service connection has been met. Second, the Board finds that the evidence of record does not support a finding that the headaches are caused or aggravated by service-connected mental health disorders. The Board notes that over the course of the period on appeal the Veteran’s mental health disorder included service-connected anxiety disorder, posttraumatic stress disorder, major depressive disorder, and panic disorder. The most probative evidence of record shows headaches are not caused or aggravated by service-connected mental health disorder. In a January 2017 opinion, the examiner opined that headaches were not caused or aggravated by service-connected anxiety. In an August 2018 VA examination, the examiner opined that the headaches were not caused or aggravated by the service-connected anxiety as there was no supporting clinical evidence. In a September 2019 VA addendum opinion, the examiner opined that there is no clinical evidence that the Veteran’s headache conditions have been aggravated by any cause including the anxiety disorder. The opinions were conclusory and did not provide an adequate rationale. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). A March 2020 VA opinion was provided. The examiner opined that the headaches were less likely than not proximately due to or the result of the Veteran’s service-connected condition, explaining the conditions are not medically related. The examiner cited to medical literature to support the conclusion. The examiner opined the Veteran’s headaches were not caused or aggravated by the service-connected anxiety, explaining in part that there is no documentation that shows chronicity of care, chronic complaints or escalation of treatment with daily prophylactic meds or Botox injections. Thus, no aggravation is plausible. The Board affords some probative weight to the causation opinion because it was supported by cited medical information. The Board affords no probative weight to the aggravation portion of the opinion. A March 2018 VA treatment record, noted daily headache pain, and the Veteran was prescribed combination medication used to treat tension headaches –is a sedative that helps to decrease anxiety. The rationale for the aggravation opinion is based on an inaccurate factual premise. A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran received a June 2020 VA examination and opinion. The examiner opined the Veteran’s headaches were less likely as not due to or the result of posttraumatic stress disorder, major depressive disorder, and panic disorder (also claimed as anxiety disorder). The examiner stated all available records were reviewed and medical literature did not support causation. The Board affords the opinion low probative weight. First, the examiner failed to address aggravation. In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Second, the examiner’s opinion does not provide an adequate rationale. 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). A November 2020 opinion was provided. The examiner opined that headaches were less likely than not proximately due to or the result of the service-connected condition. The examiner stated all medical records, remand documents, and Veteran’s statements were reviewed. The examiner determined there was no credible medical evidence to support a causal link between migraines and anxiety disorder. The examiner explained that the current state of knowledge around migraines suggest that migraines are caused by a primary neuronal dysfunction which includes both a genetic component and a hormonal component. The examiner went further to explain migraines are a common disorder that affects up to 12% of the general population to include those without a mental health condition. The examiner cited to current medical literature. The examiner also opined there was no credible medical evidence to support the suggestion that migraines were subject to aggravation by a mental health condition to include anxiety. The examiner explained there was no mechanism for aggravation by anxiety and cited to medical literature. The examiner provided a January 2021 addendum. The examiner stated they reviewed the articles submitted by the Veteran and noted any professional review of the articles was in question. The examiner determined the articles were internet/informational based and did not include references or mention of credible medical evidence/research. The examiner explained the articles were not peer reviewed literature and therefore not considered valid medical research. The examiner reiterated the opinions provided and cited to medical literature. The Board affords significant probative weight to the March 2020 causation opinion, November 2020 opinions, and January 2021 addendum opinions. First, the opinions cite to medical research. Second, the January 2021 addresses the Veteran’s contentions and information cited in the August 2020 brief. Third, the November 2020 adequately addresses aggravation. Lastly, there are no contrary opinions of record. The August 2020 brief indicated the Veteran believes his headaches are caused or aggravated by service- connected mental health disorders. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the etiology of an internal neurological condition. 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); Kahana v. Shinseki, 24. Vet. App. 428 (2011). In a March 2021 brief, the Veteran’s representative indicated headaches were the result of head trauma in-service and this was not considered. The Board finds this statement not credible. First, the January 2020 Board decision addressed direct service connection. Second, in a recent August 2020 VA treatment record the Veteran denied head trauma and denied headaches. Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, consistency with other evidence), aff’d, 78 F.3d 604 (Fed. Cir. 1996). Accordingly, the Board affords no probative weight to the contentions in the March 2021 brief. Thus, the Board gives more probative weight to the March 2020 causation opinion, November 2020 opinions, and January 2021 addendum opinions. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Bruton, 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.