Citation Nr: 21023993 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 17-35 203 DATE: April 21, 2021 REMANDED Entitlement to service connection for migraine headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1979 to March 1982. This matter comes before the Board of Veterans’ Appeal (Board) on appeal from a September 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In August 2020, the Veteran testified during a Board videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. 1. Entitlement to service connection for migraine headaches is remanded. The Veteran contends that his migraine headaches first onset in service. He noted that he began experiencing headaches in service and was assessed with spinal meningitis. He reported continuous headaches since service. The Board notes that the Veteran’s service treatment records are not of record; however, the Veteran did submit a June 1979 report indicating that he had been admitted for a 2-week period from May to June 1979 with complaint of lethargy, vomiting, and headache. He was hospitalized at the Kimbrough Army Hospital with a presumptive diagnosis of bacterial meningitis. The Veteran also submitted a statement dated in September 2018 from Dr. R. J. reflecting treatment for migraines. The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires the VA to assist a claimant in obtaining that evidence. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Given the in-service report of headache and meningitis, the Veteran’s report of headaches in and since service, and the post-service diagnosis of migraine headaches, the Board finds that remand is warranted to afford the Veteran an examination with medical opinion based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly-stated rationale. Moreover, the Board believes that additional attempts to obtain the Veteran’s service treatment records, including records from the Veteran’s National Guard service from 1983 to 1989, should be undertaken. A May 2018 correspondence reflects that the RO attempted to obtain these records from the National Personnel Records Center (NPRC), which indicated that the records were not available. While on remand, efforts to obtain these records from all potential sources should be obtained, and if not found, a formal finding as to their unavailability should be prepared and associated with the claims file. Finally, the Veteran should be asked to submit or provide VA authorization to obtain the outstanding treatment records from Dr. R. J. and any other relevant treatment providers. The matter is REMANDED for the following action: 1. Assist the Veteran in associating with the claims folder outstanding treatment records, to specifically include updated VA treatment records. The AOJ should take appropriate steps to send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization, to enable it to obtain any additional evidence pertinent to the claims on appeal, to specifically include treatment records from Dr. R. J. If the Veteran identifies any other pertinent medical records that have not been obtained, the AOJ should undertake appropriate development to obtain copies of those records. 2. The AOJ should attempt to obtain records of treatment from the Veteran's period of active service from January 1979 to 1982, as well as treatment from his National Guard Service from 1983 to 1989, from all potential sources, to include the RMC and the Veteran's National Guard component. All efforts in this regard should be documented in the claims file, and if these records are unavailable, a memorandum should be prepared and associated with the claims file. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed migraine headaches. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history. The examiner should address whether it is at least at likely as not that the Veteran's headaches had its onset in service or within one year of discharge, or is otherwise related to service, to include the reports of treatment for headaches and bacterial meningitis therein. The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. E. Wilkerson, 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.