Citation Nr: 21021570 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 14-37 155 DATE: April 13, 2021 REMANDED Service connection for headaches, to include migraine headaches and tension headaches.   REASONS FOR REMAND The Veteran served on active duty from April 2003 to April 2010. The case is on appeal from a July 2013 rating decision. In May 2018, the Veteran testified at a Board hearing. In a July 2018 decision, the Board granted service connection for sleep apnea. At that time, the Board also remanded the claim of service connection for headaches for additional development. The Board again remanded the claim for additional development in January 2020 and December 2020. Service connection for headaches, to include migraine headaches and tension headaches. The Veteran is seeking service connection for a headache condition. He contends that he experienced migraine headaches prior to service which increased in severity and frequency during service. Hr’g. Tr. at 6-7. Alternatively, the Veteran testified that he experiences tension headaches that are distinct from his migraine headaches. Hr’g. Tr. at 7-8. The Veteran also contends that his tension headaches and migraine headaches are caused by or aggravated by his service-connected post-traumatic stress disorder (PTSD). In addition, the Board found that the question of whether the Veteran’s headaches are secondary to his service-connected sleep apnea was raised by the record. The Board previously remanded the claim in December 2020. Pursuant to the Board’s remand, an opinion was obtained in January 2021. However, the Board finds that the January 2021 opinion is not entirely sufficient to decide the claim. In this regard, the examiner determined that it is less likely than not that the Veteran’s headaches are aggravated by his sleep apnea. The examiner stated that there is no evidence in the medical records to support that the Veteran’s sleep apnea aggravates his migraine headaches. However, the evidence of record indicates that there is potentially a relationship between the severity of the Veteran’s headache condition and his sleep apnea. In this regard, at the May 2018 Board hearing, the Veteran stated that since using a CPAP machine to treat his sleep apnea, his headache condition improved. In addition, a July 2016 VA treatment record similarly reflects that the Veteran reported less headaches upon using his new CPAP machine. Accordingly, a new examination and opinion are warranted on remand that addresses this relationship. In addition, concerning the Veteran’s tension headaches, the examiner who provided the January 2021 opinion only addressed the Veteran’s migraine headaches. However, the Veteran testified at the May 2018 Board hearing that he experiences tension headaches that are distinct from his migraine headaches, which he believes did not preexist his military service. Hr’g. Tr. at 7-8. The Board notes that a September 2011 VA treatment record reflects a diagnosis of tension headaches. As such, an opinion is needed to remand to determine whether the Veteran is entitled to service-connection for tension headaches under the direct theory of service connection. The examiner also did not address whether the Veteran’s tension headache condition is secondary to, i.e., caused or aggravated by, his service-connected PTSD and/or his sleep apnea pursuant to 38 C.F.R. § 3.310. In this regard, the Veteran specifically contends that there is a relationship between his headaches, blood pressure, and PTSD. The examiner who provided the January 2021 opinion did not address this relationship as it pertains to the Veteran’s tension headaches. Accordingly, a new examination and opinion are warranted on remand. In light of the remand, updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain VA treatment records since January 2021. 2. Schedule the Veteran for a VA examination (or telehealth interview, record review, etc., if an in-person examination is not feasible) by a qualified medical professional for an opinion to determine the nature and etiology of any headache condition. The examiner should specifically address: Whether the Veteran has current diagnosis for any and all headache conditions, to include migraine headaches and tension headaches. If the Veteran previously had any such medical condition, but his no longer extant, the examiner should identify when that condition resolved. Whether the Veteran’s migraines and/or tension headaches clearly and unmistakably (i.e., medically undebatable) preexisted service. If so, whether the Veteran’s migraines and/or tension headaches were clearly and unmistakably (i.e., medically undebatable) not aggravated by service. Note that in this context aggravation means permanent worsening beyond the natural progression of the disease or a temporary flare-up. If the Veteran’s migraines and/or tension headaches did not preexist or were aggravated by service, is it at least as likely as not (50 percent or greater probability) that the Veteran’s migraines and/or tension headaches are related to service. Whether it is at least as likely as not that the Veteran’s migraines and/or tension headaches were caused or aggravated by his service-connected PTSD. The examiner should consider the Veteran’s contention that there is a relationship among increases in the Veteran’s blood pressure, his PTSD, and his headaches. Whether it is at least as likely as not that the Veteran’s migraines and/or tension headaches were caused or aggravated by his service-connected sleep apnea. The examiner should consider the Veteran statements concerning improvement in his headache condition when using a CPAP machine to treat his sleep apnea. Note that in this context aggravated means any increase in severity beyond the natural progress of the disease. The examiner is to consider the migraine headache condition as distinct from the tension headache condition. A complete rationale should be provided for any opinions reached. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Gray, 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.