Citation Nr: 21021872 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 16-09 985 DATE: April 14, 2021 REMANDED Service connection for headaches is remanded. REASONS FOR REMAND The Veteran served in the Air Force from September 1960 to June 1965. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 2012 rating decision. In May 2019, the Veteran testified at a Board video-conference hearing. In August 2019 and August 2020, the Board remanded this issue for additional development and adjudication. Another remand is needed. 1. Service connection for headaches is remanded The September 2020 VA examination did not substantially comply with the August 2020 Board remand directives, and another medical opinion is needed. Although the examiner gave an adequate rationale as to service connection as secondary to hypertension, the examiner’s rationale was insufficient and based on an inaccurate factual history concerning whether it is secondary to a mental health disorder. As noted in the prior remand, the Veteran asserts that he began having stress-induced headaches either shortly before his discharge from service in 1965 or shortly after his discharge from service, and that a private provider prescribed Valium to treat his stress and headaches. However, as explained in the prior remand, the currently available evidence (including records since remand) does not corroborate the Veteran’s reports of having headaches continuously since service. He repeatedly denied headaches in available records until October 2012, under circumstances where he would have been expected to report headaches if present. The September 2020 VA examiner, who also provided the opinions in a VA headaches examination in January 2020, stated that the Veteran’s headaches were less likely than not caused or aggravated by his service-connected major depressive disorder because the Veteran reported during the January 2020 VA examination that his headaches began prior to service in 1960 and were aggravated by noise in service. However, the January 2020 VA examination report reflect that the Veteran stated that his headaches began prior to his discharge from service in 1965 and that he believed they were related to noise in service. Additionally, as noted above, the Board found that the evidence did not corroborate headaches continuously since service. Likewise, the Veteran’s entrance examination for service in 1960 noted that the Veteran denied frequent or severe headaches and was clinically normal. Therefore, the September 2020 opinion was based on an inaccurate factual history and is inadequate. An addendum opinion should be obtained from a different examiner, if possible, based on the correct facts for this Veteran’s case. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician, using a different examiner than G.A. who gave the January 2020 and September 2020 headache opinions, if possible, to address whether it is at least as likely as not that the Veteran’s tension headaches or migraine headaches were caused or aggravated by his service-connected major depressive disorder. For this purpose, aggravation means any incremental increase in disability in a non-service-connected disability (i.e., any additional impairment of earning capacity) resulting from a service-connected condition. The examiner should consider the facts of this case, including the correct timing of his headaches. In particular, as noted in the narrative of the current and prior Board remands, there is no indication of headaches associated with a neck or shoulder disorder, or that his headaches were present prior to service in 1960. Instead, the Veteran denied headaches at service entrance in 1960 and exit in 1965, and for many years after discharge, until he reported headaches in mental health evaluations in 2012 and 2020. The examiner should address the significance of the Veteran’s assertions of having headaches related to stress, and his 70 percent rating for major depressive disorder effective since 2010. The examiner is asked to explain the reasons behind any opinions and conclusions expressed. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If an opinion cannot be provided without resort to mere speculation, the examiner should explain why that is so. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Wheatley 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.