Citation Nr: 21024184 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 16-29 700 DATE: April 22, 2021 ORDER Entitlement to service connection, to include on a secondary basis, for a migraine disability, to include migraine variants, is denied. FINDING OF FACT The Veteran’s migraine disability, to include migraine variants, did not originate in service or until years thereafter, is not otherwise etiologically related to service, and was not proximately due to or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection, to include on a secondary basis, for a migraine disability, to include migraine variants, have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1997 to July 2004. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The appeal was last remanded by the Board in October 2018 for additional development. A review of the claims file shows that there has been substantial compliance with the Board’s prior remand directives and thus, no further action in this regard is warranted. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for a left hip disability was previously on appeal. On remand, the RO awarded service connection for a left hip disability in a July 2020 rating decision. A VA Form 10182, Notice of Disagreement, has not been filed in response to the July 2020 rating decision. Accordingly, the only issue before the Board is entitlement to service connection for a migraine disability, to include migraine variants. Entitlement to service connection, to include on a secondary basis, for a migraine disability, to include migraine variants The Veteran contends that her migraine disability is secondary to her service-connected cervical spine disability. The Board notes that the Veteran is a registered nurse at a VA medical center. In a June 2016 VA Form 9, the Veteran explained that the joint spaces in her neck continued to degenerate becoming smaller and compressing the nerve roots as they emerge from her spine. She alleged that she had been able to correlate symptomatic exacerbations of her cervical spine disability to the onset of her migraines and stated: “For example, as the disc spaces in my neck have narrowed, thereby causing worsening pain and spasm, the migraines have become increasingly frequent and debilitating over time.” The Veteran also stated that she did not have migraines until her neck pain began to worsen. Factual Background An August 1996 report of medical history at the time of enlistment notes that the Veteran did not have frequent or severe headaches nor a history of a head injury. An undated service treatment record notes that the Veteran had a sore throat, runny nose, and headache lasting two days. Another undated service treatment record with a chief complaint of vomiting and diarrhea noted that the Veteran reported a headache too. A December 2003 service treatment record notes that the Veteran was evaluated for environmental allergies during which she reported pressure headaches as one of her symptoms. An April 2004 report of medical history notes that the Veteran did not have frequent or severe headaches nor a history of a head injury. A June 2012 VA treatment record documents the result of a computerized tomography (CT) scan. The reason for the study was that the Veteran reported headaches with loss of vision. The CT impression noted a small cortical hypodensity left occipital pole, seen on a single slice and stated “[w]hile this may represent bone volume averaging, small cortical infarct not excluded.” An October 2013 VA treatment record noted that the Veteran experienced recurrent migraines that began one year ago with loss of vision in her right eye that was reversible but concerning. The October 2013 VA treatment record further noted that the Veteran had undergone a magnetic resonance imaging (MRI) performed by a neurologist who told the Veteran that she had migraines. The Veteran reported that her migraines typically occurred at work and occasionally at home and that her migraines usually started with neck pain, photosensitivity, phonophobia, and occasional flashing lights in her peripheral vision. The October 2013 record noted that the Veteran had migraines with aura and that the unilateral vision loss suffered last year made an aura diagnosis more likely. A November 2013 VA treatment record again noted the Veteran’s history of recurrent migraines beginning one year prior. However, the November 2013 VA treatment record and an October 2014 VA treatment record noted that the Veteran did not have any new headaches or change in vision, focal neuro deficits, or new sensory or motor dysfunction. The October 2014 VA treatment record again noted the Veteran’s history of migraines that initially began with loss of vision in the right eye. The October 2014 VA treatment record also noted that the Veteran had migraines with aura and visual disturbances The Veteran was afforded an in-person VA examination for her migraine disability in January 2015. The examiner noted a diagnosis of migraine including migraine variants. The January 2015 VA examiner’s report documented the Veteran’s history including that her migraines began approximately two years prior when she lost vision in her right eye while working and had a headache afterward. The Veteran reported that her headaches started in her neck area where she had tension and then shot forward into her forehead. She also reported that she saw flashing lights before the headaches and had occasional vomiting. She also reported that her headaches only happened at work and occurred monthly. She also reported symptoms of photophobia and phonophobia with her headaches and pain on both sides below her cheeks. The Veteran reported that she had headache pain that was pulsating or throbbing head pain, worsened with physical activity, and resulted in tense pain in her shoulders. The head pain was located in both sides of her head and lasted 1 to 2 days. Non-headache symptoms included vomiting, sensitivity to light, sensitivity to sound, changes in vision (such as scotoma, flashes of light, and tunnel vision). The VA examiner determined that the Veteran’s migraine disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner conceded that records referenced by the Veteran from a private neurologist and the Denver VA medical center were not available at the time of examination. However, the VA examiner noted that the January 2012 VA examiner’s report addressing her service-connected cervical spine disability was silent for any mention of cervical related headaches. The VA examiner also noted a gap between the 2004 motor vehicle accident that caused the Veteran’s service-connected cervical spine disability and the first mention of migraines with aura in October 2013. The VA examiner further explained that migraines with aura are a separate mutually exclusive disorder than a cervicogenic headache. August 2015 and October 2015 VA treatment records note that the Veteran had a history of migraines and chronic neck and low back pain. A May 2016 VA treatment record noted that the Veteran had migraines with aura. May 2018 and March 2019 VA treatment records note that the Veteran had migraines that began in 2013 with lost vision in her right eye, which was reversible but still concerning. The records also note that the Veteran had chronic neck and low back pain. The records again note that a neurologist had performed an MRI and told the Veteran that she had migraines. The March 2019 VA treatment record notes that migraine with aura was an active problem. The Veteran was afforded another in-person VA examination in December 2019. The VA examiner noted that the Veteran was diagnosed with migraines, including migraine variants, in 2010. The Veteran reported headache pain on both sides of her head. She also reported non-headache symptoms including nausea, vomiting, sensitivity to light, sensitivity to sound, changes in vision (such as scotoma, flashes of light, tunnel vision), and sensory changes (such as feeling of pins and needles in her extremities). The Veteran’s migraine history was noted with migraines beginning in 2010. The Veteran explained that neck pain was always present before her headaches. The December 2019 VA examiner provided a direct nexus opinion and determined that the Veteran’s migraines were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness because the Veteran’s migraines were not treated in service or for many years thereafter. The December 2019 VA examiner also provided a secondary causation and a secondary aggravation opinion addressing each of the Veteran’s service-connected disabilities and whether the service-connected disability was related to her migraine disability. First, the VA examiner found against a nexus between the Veteran’s migraines and her service-connected lumbar disability. The examiner explained that headaches, including migraines, can be related to cervical degenerative disc disease, but not likely lumbosacral disease. Therefore, the examiner concluded that it was likely than not that the Veteran’s headaches were due to or aggravated by her service-connected lumbosacral spine disability. Second, the VA examiner found against a nexus between the Veteran’s migraines and her service-connected human papilloma virus (HPV). The VA examiner determined that the Veteran’s migraine disability was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected HPV. The VA examiner also determined that the Veteran’s migraines were not aggravated by her service-connected HPV. The VA examiner explained that there was “no relationship whatsoever between HPV and migraine headaches.” Third, the VA examiner found against a nexus between the Veteran’s service-connected hysterectomy residuals and her migraine disability. The VA examiner determined that the Veteran’s migraines were not due to or aggravated by her service-connected hysterectomy residuals. The VA examiner explained, there is no relationship between migraines and gynecological conditions or surgeries. Fourth, the VA examiner determined that the Veteran’s migraines were less likely than not proximately due to or the result of the Veteran’s service-connected right upper extremity radiculopathy. The VA examiner also determined the Veteran’s migraine disability was less likely than not aggravated beyond its natural progression due to or the result of the right upper extremity radiculopathy. The VA examiner explained there is no association between radicular symptoms of the upper extremity and migraine headaches. Fifth, the VA examiner determined that the Veteran’s migraine disability was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected scar(s). The VA examiner also found against a secondary aggravation theory of entitlement. The VA examiner explained that there was no relationship between migraines and gynecological conditions or surgeries with scars. Lastly, the December 2019 VA examiner found against secondary causation and secondary aggravation of the Veteran’s migraine disability due to her service-connected cervical spine disability. The VA examiner determined that it was less likely than not (less than 50 percent probability) that the Veteran’s migraine disability was proximately due to or the result of the Veteran’s service-connected cervical spine disability. The VA examiner also determined that it was not at least as likely as not that the Veteran’s migraines were aggravated beyond the natural progression by the Veteran’s service-connected cervical spine disability despite the Veteran’s migraines having increased in severity since 2013. The VA examiner explained that the Veteran did not have cervicogenic headaches that arose from the cervical spine. The VA examiner stated: The term cervicogenic headache is commonly misused and does not simply apply to a headache associated with neck pain; many headache disorders, including migraine and tension-type headache, can have associated neck pain or tension. Rather, there must be evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause a headache. Such disorders include tumors, fractures, infections, and rheumatoid arthritis of the upper cervical spine. The VA examiner noted that while the Veteran had radicular pattern at C8 and minimal narrowing at C4 to C5, there was no evidence of occipital involvement or upper cervical root involvement contributing to cervicogenic headaches. Instead, the VA examiner determined that the Veteran’s neck stiffness and tension arising from the occiput and wrapping around the head were attributed to the migraine headache with tension type features. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Service connection generally requires evidence satisfying three criteria: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (“nexus”) between the current disability and the disease or injury incurred or aggravated during service. Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). Secondary service connection may be granted when a disability is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 447-48 (1995). VA treatment records consistently show that the Veteran has a migraine disability that began in approximately 2012 and the January 2015 and December 2019 VA examiner’s reports also note a diagnosis of migraine, including migraine variants. Therefore, the Board finds that the first prong of service connection has been met. The Veteran does not contend, and the evidence does not show that the Veteran’s headaches are directly related to her active duty service. While headaches were occasionally noted in-service, the Board emphasizes that each time a headache was noted in the Veteran’s service treatment records the headaches were associated with another illness or allergies. The Board agrees with the December 2019 VA examiner’s finding against a direct nexus between the Veteran’s migraine disability and her active duty service. The Board also notes that approximately 8 years passed between the Veteran’s separation from active duty service and her first symptoms of a migraine disability in 2012. The Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning a claimant’s health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Accordingly, the Board finds that service connection on a direct basis is not warranted. (Continued on the next page)   Currently, the Veteran has been awarded service connection for a hysterectomy disability, a lumbar spine disability, a cervical spine disability, upper right extremity radiculopathy, a left hip disability, HPV, and a scar. The Veteran does not argue and the evidence does not show that the Veteran’s migraine disability is related to her service-connected hysterectomy disability, lumbar spine disability, upper right extremity radiculopathy, left hip disability, HPV, or scar. See June 2016 VA Form 9 and December 2019 VA examiner’s report. Instead, the Veteran argues that her migraine disability is caused by or aggravated by her cervical spine disability. The Board notes that the October 2013 VA treatment record, January 2015 VA examiner’s report, and December 2019 VA examiner’s report document the Veteran’s reports that her migraines begin with pain in her neck. While the Board acknowledges that the Veteran is a nurse and competent to report her symptoms and an etiology, the Board affords greater probative weight to the December 2019 VA examiner’s report which cited to medical literature and evidence in the record in support of the negative nexus opinions provided therein. The December 2019 VA examiner explained that the term cervicogenic headache is commonly misused and does not simply apply to a headache associated with neck pain. The December 2019 VA examiner explained that tumors, fractures, infections, and rheumatoid arthritis of the upper cervical spine are examples of causes of cervicogenic headaches. Nothing in the record indicates that the Veteran had a tumor, fracture, infection, or rheumatoid arthritis of the cervical spine. Instead, the Board emphasizes the December 2019 VA examiner’s finding that the Veteran’s neck stiffness is attributed to her migraine disability. The Board also notes that VA treatment records indicated that the Veteran had migraines with aura. The January 2015 VA examiner found that migraines with aura are also a separate mutually exclusive disorder than a cervicogenic headache. The Board agrees with the January 2015 and December 2019 VA examiners’ findings that the Veteran did not experience cervicogenic headaches. The Board also agrees with the January 2015 and December 2019 VA examiner’s opinions that the Veteran’s cervical spine disability did not cause or aggravate her migraine disability. Accordingly, service connection on a secondary basis is not warranted. The preponderance of the evidence is against the claim. Service connection for cause of the Veteran’s migraine disability must be denied. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Palombi, Jessica R 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.