Citation Nr: 21021585 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 16-23 224 DATE: April 13, 2021 ORDER Entitlement to service connection for headaches is denied. FINDING OF FACT The Veteran’s headaches are not secondary to service-connected Hepatitis C or leukemia, and are not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for headaches due to service or service-connected disease or injury are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1978 to October 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The claim was previously before the Board in May 2019, at which time the Board remanded the claim for further development. There has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). These duties have been satisfied in this case. Appropriate notice was provided in December 2013. The RO associated the Veteran’s service and VA and private outpatient treatment records with the claims file. The Veteran was notified of the attempts to obtain records from Dr. Clark, both requests were returned as undeliverable, and Feather River Hospital responded that there were no records for the Veteran. The rating decision on appeal noted that there were no responses received from Feather River Hospital or Dr. Edgar Clark and the Veteran was notified of the final attempts to obtain the records. 38 C.F.R. § 3.159(e). No other relevant records have been identified and are outstanding. Appropriate and necessary examinations were afforded the Veteran, and are adequate for evaluation, as they include needed findings to permit application of the rating schedule and identification of current disability. In this respect, the Board finds that the 2013 VA medical opinion as to a relationship between headaches and leukemia and the 2016 medical opinion as to whether the Veteran’s headaches were proximately caused by his hepatitis C, are adequate when taken together with the August 2020 VA addendum opinion. In this respect, the 2013 and August 2020 opinions addressed the evidence of record and the August 2020 VA addendum opinion specifically addressed the contentions as to a relationship between chemotherapy and headaches and noted the medical literature. The 2016 and August 2020 addendum opinions addressed the evidence of record, medical history, and medical literature concerning hepatitis C and headaches. The August 2020 addendum opinion also specifically addressed proximate causation as well as aggravation. See 38 C.F.R. § 3.310. In addition, the February 2020 opinion is adequate concerning direct service connection, noting the evidence reviewed and the Veteran’s own statements. Thus, the Board’s remand has been completed. As such, VA has satisfied its duty to assist. Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Entitlement to service connection for headaches is denied. The Veteran contends that his headaches are secondary to his service-connected Hepatitis C or leukemia. See February 2014 correspondence; see November 2015 VA examination for headaches. Under the relevant laws and regulations, 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. Generally, the evidence 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. Shedden v. Principi, 391 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Service treatment records (STRs) do not show that the Veteran suffered from headaches while in service. The Veteran’s October 1978 entrance examination did not reveal any headache related problems. His STRs are absent of any complaints, treatment, or diagnosis of headaches. He denied any frequent or severe headaches in the August 1979 report of medical history. His August 1979 separation exam noted his head was normal, and there was no indication of a headache related condition. A January 1982 letter from Dr. Williams noted that the Veteran was seen for the sudden development of a unilateral right-sided headache. There was no past history of a migraine, family or personal. It was noted that the headache originally occurred the day before lasting several hours. The Veteran was given Demerol 50 mg. every 4 hours for the next week in case of headache recurrence. In another January 1982 letter, it was noted that the difficulties with a unilateral headache had completely resolved. Subsequently, in a March 1982 private record, the Veteran’s treating oncologist Dr. Williams noted that she is investigating recent “incapacitating headaches of migraine variant which by virtue of CAT [computerized axial tomography] scan and spinal fluid appear not to be a relapse of his leukemia,” however, time could prove this original impression to be wrong. In a June 1983 Physical Evaluation Board record from neurology, the clinician’s impression was head pains with unknown etiology. The clinician further noted that the Veteran’s head pains were not typical of migraines, and he doubted any relationship to chemotherapy. VA treatment records from September 2009 to October 2010 note an assessment of mild hepatic dysfunction. A November 2010 VA treatment record noted that the Veteran’s lab results revealed he was positive for Hepatitis C. VA treatment records thereafter noted assessment and treatment plans for Hepatitis C. In an April 2013 VA examination for headaches, the examiner opined that the Veteran’s headache condition is less likely as not permanently aggravated or a result of leukemia and/or chemotherapy for leukemia, and is at least as likely as not a result of unknown factors. The examiner noted that the natural progression was not altered or worsened by any event or condition that occurred during active service. The examiner further noted that the Veteran’s treating oncologist reported no association between headaches and leukemia in March 1982, and that a June 1983 neurology opinion reported no association between chemotherapy and headaches. The examiner noted he concurred with those findings. A June 2013 VA treatment record noted that the Veteran is patient with hypothyroidism and Hepatitis C that were discovered after a screening test for employment at a VA facility. The Veteran reported occasional migraine headaches that were tolerable and usually managed without medication. In October 2013, a lay statement was received from the Veteran’s former wife. She noted she was married to the Veteran from 1981 to 1997. She noted that the Veteran developed migraine headaches in early 1980s following chemotherapy for leukemia. She noted that his headache episodes were unpredictable, and that his doctors were unable to associate them with allergies, stress, or any other outside factor. She noted that the Veteran’s oncologist thought they were a result of the leukemia and subsequent chemotherapy. She noted that his migraine headaches have continued on for more than 30 years. In a March 2014 VA contract examination for headaches, the Veteran was diagnosed with migraine including migraine variants. The Veteran stated he first noticed the onset of headaches in 1982 that persist to date. He stated that since his treatment for Hepatitis in 2010, the headaches have become more severe. The exam did not provide any nexus opinion. In a March 2014 VA contract examination for Hepatitis, the Veteran reported that he was diagnosed with Hepatitis C in 2010 after pre-employment testing. He reported that he was treated with Pegasys. He reported he currently has night sweats, fatigue, and headaches that have become more pronounced since his treatment. In a November 2015 VA examination for headaches, the Veteran was diagnosed with migraine including migraine variants. The Veteran stated that he felt his headaches were secondary to his treatment for leukemia. He reported he has suffered with the condition monthly since around 1986. The examiner did not provide a nexus opinion. A VA medical opinion was received in April 2016. The VA examiner opined that the Veteran’s migraine headaches are less likely than not proximately due to or the result of the Veteran’s service-connected Hepatitis C. The examiner explained that there are many causative factors for migraine headaches, but none in the scientific literature were related to Hepatitis C. The examiner added that the etiology of the Veteran’s migraine condition is unknown. An April 2019 VA treatment record noted “no headaches” in review of systems. At a February 2020 VA contract examination, the Veteran reported he was diagnosed with acute leukemia around 1979. He reported he was treated with blood transfusions and believed that he contracted Hepatitis C during that time frame, but was not diagnosed until 2010. He stated initial headaches occurred in 1982, and they got worse when he started receiving treatments for Hepatitis C during 2010. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that while one of the symptoms of leukemia is headaches, the Veteran reported his headaches began around 1982 during which time he was in remission from his leukemia. The examiner further noted that he did not find any indication from STRs that the Veteran was experiencing headaches during service. The examiner also opined that it is at least as likely as not that the headaches are proximately due to or the result of the Veteran’s service-connected Hepatitis C or leukemia. The examiner noted that the Veteran was diagnosed with leukemia around 1979 and received multiple blood transfusions to treat his leukemia, and that it is most likely that the Veteran contracted Hepatitis C from a transfusion. The examiner wrote the Veteran began experiencing headaches in 1982, and that headache is one of the symptoms of Hepatitis C. The examiner also noted that the Veteran reported exacerbation of his headaches in 2010 when he started to receive Pegasys, a treatment for Hepatitis C, and that headache is a side effect of Pegasys. The examiner noted that although there are several potential etiologies for migraines, there is no indication from the Veteran’s records he had any other underlying cause for his headaches. In July 2020, the RO found that the February 2020 opinion was not adequate as to secondary service connection and in conflict with the evidence of record because the examiner concluded that the Veteran’s headaches preceded the diagnosis for Hepatitis C. An addendum opinion was requested. An addendum opinion was received in August 2020. The examiner opined that it is less likely as not that the Veteran’s migraines are caused by his service-connected Hepatitis C or leukemia. The examiner explained that, although the Veteran received Pegasys in 2011 to treat Hepatitis C, “the headache associated with Pegasys is during treatment with the drug and not a long term side effect.” The examiner noted that the February 2020 opinion that the Veteran’s headaches are at least as likely as not secondary to the service-connected Hepatitis C or leukemia was not supported by the weight of medical evidence. She noted that UpToDate’s review of extrahepatic manifestations of Hepatitis C virus infection was silent for headache as a secondary symptom of Hepatitis C. She also noted that chemotherapy for leukemia in 1979-1980 does not cause migraine headaches, and any acute headaches related to chemotherapy would not continue for decades afterwards. She added that neurology consult in 1983 noted headaches are not typical of migraines, and are not related to chemotherapy or leukemia. The examiner also noted she concurred with the April 2013 medical opinion which found it less likely as not that the headaches were secondary to the service-connected leukemia or its treatment, and with April 2016 medical opinion which found it less likely as not that the headaches were secondary to his service-connected Hepatitis C. The examiner also opined that it is less likely as not that the Veteran’s migraines are aggravated by his service-connected Hepatitis C or leukemia. The examiner noted that UpToDate review of extrahepatic manifestations of hepatitis C virus infection is silent for headache as aggravated by Hepatitis C. She noted that chemotherapy for leukemia in 1979-1980 would not aggravate current claimed migraine headaches decades later, and that the neurology consult in 1983 noted headaches were not typical of migraines and not related to chemotherapy or leukemia. The Board first concludes that service connection is not warranted on a direct basis. As expressed in the February 2020 negative etiology opinion, the examiner explained that the Veteran was treated for leukemia during service, but that the Veteran himself did not indicate that he had headaches during service. Instead, the Veteran asserted that his headaches began in approximately 1982 as a result of his chemotherapy. There is no evidence of any headaches in the service treatment records. Accordingly, a preponderance of the evidence is against the claim and service connection on a direct basis is not warranted. The Board also finds that the preponderance of the evidence is against the finding that the Veteran’s headaches are caused or aggravated by his service-connected Hepatitis C or leukemia. The April 2013 and August 2020 VA examiners opined that that the Veteran’s headaches were not caused or aggravated by his leukemia. The examiners explained that chemotherapy for leukemia does not cause or aggravate headaches, and that any acute headaches related to the chemotherapy would not continue for decades. They also referred to a 1983 neurology consult that noted that his headaches were not related to the chemotherapy for leukemia. The April 2016 and the August 2020 VA examiners opined that the claimed headaches were not caused or aggravated by his Hepatitis C. They explained that medical literature did not support that Hepatitis C caused or aggravate headaches, and that Pegasys used in 2011 would not produce long term side effects. These opinions are well reasoned, detailed, consistent with the other evidence of record, and included consideration of the relevant history. Accordingly, the opinions are entitled to great probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). The February 2020 examiner opined that it is at least as likely as not that the Veteran’s headaches are proximately due to his Hepatitis C. The examiner noted that the Veteran was diagnosed with leukemia around 1979, and that he likely contracted Hepatitis C during a blood transfusion for his leukemia. The examiner also mentioned that the Veteran began experiencing headaches in 1982, and that headache was a symptom of Hepatitis C. The examiner also mentioned that the Veteran reported exacerbation of headaches in 2010, which was close to the time the Veteran used Pegasys, that had headaches as a side effect. However, the February 2020 opinion appears to be based on assumption and self-reported medical history. While the Veteran might have contracted Hepatitis C around the time of the diagnosis of leukemia, the medical records show that he was clinically diagnosed with Hepatitis C in 2010. Further, while the examiner relates the Veteran’s use of Pegasys and the Veteran’s self-reported exacerbation of his headaches around 2010, VA treatment records do not reveal any complaints of headaches from 2009 to 2012, and only one treatment record in June 2013 noted occasional, tolerable headaches. Thereafter, the records are silent for a complaint or treatment for headaches. Nieves-Rodriguez, 22 Vet. App. at 304. Consequently, the Board gives more probative weight to the April 2013, April 2016, and August 2020 VA examiners’ opinions. The Board has considered the Veteran and his former wife’s contentions that his headaches were caused or aggravated by his service-connected Hepatitis C or leukemia. The Veteran and his former wife have not shown to hold qualifications to challenge the medical conclusions at issue. Issues of causation or aggravation are medically complex, and they are not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Further, while the Veteran’s former wife asserted that the Veteran’s oncologist thought the headaches were a result of his leukemia and subsequent chemotherapy, the oncologist Dr. D.W. noted in the June 1982 record that the Veteran’s recent headaches were not related to his leukemia. In conclusion, the Board finds that the preponderance of the evidence is against the claim of service connection for headaches. There is no doubt to be resolved, and service connection is not warranted. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). JESSICA SEAY Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Jake Choi 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.