Citation Nr: 21022444 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 16-19 547 DATE: April 15, 2021 REMANDED Entitlement to service connection for migraines, to include as secondary to service-connected depressive disorder and/or asthma is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from March 1991 to January 1994. In February 2019, the Veteran testified at a Board hearing. The transcript is of record. In June 2019, the Board remanded the case for further development, which is completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for migraines Once VA undertakes the effort to provide an examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board remanded this case in June 2019 for a medical opinion addressing secondary service connection and in March 2020 an opinion was obtained. The examiner opined that it is less likely than not that migraines are proximately due to or the result of the Veteran’s service-connected depressive disorder or asthma, to include the treatments for these conditions. The examiner stated that the two conditions are not medically related; headaches is a separate entity entirely from the service-connected asthma and depressive disorder and is unrelated to it. She noted that the disability benefits questionnaire (DBQ) clinician diagnosed migraines and the examiner explained that the etiology of migraines may be caused by changes in the brainstem and imbalances in brain chemicals. She acknowledged that the Veteran has a history of oral prednisone taper in 2014, budesonide inhaler, albuterol inhaler, singular but concluded that none cause a chronic headache condition and while albuterol can cause a headache with use, it does not cause a migrainous condition. Additionally, corticosteroids only affect the lungs and oral prednisone would not cause a chronic headache condition but rather a headache with use. She also reported that the claims folder does not indicate medication use for a depressive disorder prior to the diagnosis of headache condition. The examiner noted that the cause of migraines is not fully understood but genetics and environmental factors appear to play a role and concluded that there is not evidence to suggest that the Veteran’s headache condition is secondary to his service-connected conditions or medications. The Board finds this opinion inadequate for several reasons. First, the examiner did not address whether the Veteran’s migraines or headaches are aggravated by his depressive disorder and/or asthma. Second, the examiner seems to indicate that the Veteran has a migraine condition as opposed to a headache condition based on the DBQ findings and relies on the likely causes of migraines to support the negative nexus; however, the medical evidence supports findings of both a headache and migraine condition. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). As the medical opinion does not contain clear conclusions with supporting data and a reasoned medical explanation connecting the two, a remand is necessary. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Steal v. Nicholson, 21 Vet. App. 120, 124 (2007). The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Acquire updated VA and/or private treatment records. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 3. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s headaches and migraines are related to active service or is caused by or aggravated by military service. (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that headaches and migraines are proximately due to or the result of the Veteran’s service-connected depressive disorder and/or asthma, to include treatments? (b.) If the answer to (a) is negative, is it at least as likely as not that the headaches and migraines are aggravated (i.e., permanently or temporarily worsened) by the depressive disorder and/or asthma, to include treatments? (c.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history. The examiner should consider and discuss the Veteran’s testimony that he started having headaches after his asthma diagnosis and treatment with inhalers. As well as his report that the stress and anxiety from his depressive disorder also causes headaches which is aggravated by his asthma treatment of prednisone, Alupent and albuterol. If there is a medical basis to doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner must consider and address the following opinions: 1) the August 2016 and April 2018 opinions from D.O. See Medical Treatment Record Non-Government Facility August 2016 and Buddy/Lay Statement April 2018; and 2) the opinion of Dr. S.T. See DBQ February 2019. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Prinsen, Samantha 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.