Citation Nr: 21024846 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 16-19 954 DATE: April 26, 2021 REMANDED Entitlement to service connection, to include on a secondary basis, for headaches, to include as due to environmental exposures or undiagnosed illness or other qualifying chronic disability under 38 C.F.R. § 3.317, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1987 to August 1991. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision by a Department of Veterans Affairs Regional Office (RO). In March 2019, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. In September 2019, the Board remanded this case and instructed the Agency of Original Jurisdiction (AOJ) to obtain VA examinations. The matter was remanded again in December 2020 to obtain an addendum VA medical opinion. The requested medical opinion was obtained in February 2021, and is addressed below. Headaches As noted above, a December 2020 Board Decision remanded this matter to obtain a VA addendum opinion. In pertinent part, the Board noted that the prior January 2020 examiner noted a diagnosis for “medication overuse headaches.” The examiner opined that it was “at least as likely as not (50% or greater probability)” that the Veteran’s headache condition was due to or the result of his service-connected condition. However, the rationale noted the Veteran’s headache condition was less likely as not due to the service-connected PTSD, the only condition for which the Veteran is service connected. Additionally, while the examiner stated that the headache condition was likely associated with overuse of headache medication, he further stated that the underlying cause was unclear. For the requested addendum opinion, the Board requested the examiner to “specifically address the Veteran’s headache triggers and whether they are related to his service-connected PTSD.” The requested addendum opinion was obtained in February 2021. The examiner opined that the Veteran’s headache condition was “less likely than not (less than 50% probability) proximately due to or the result of his service-connected condition.” In support of this opinion, the examiner stated that the headaches were likely associated with overuse of Excedrin. The examiner further found it unlikely that the service-connected PTSD, or medications used to treat his PTSD, caused the headaches. In addition, the examiner opined that it was not “at least as likely as not” that the headache condition was aggravated by a service-connected disability. In support of this determination, the examiner repeated the rationale provided above. The Board finds that the examiner’s February 2021 addendum medical opinion inadequate. Specifically, with regard to the inquiry on appeal, the examiner only addressed causation and not aggravation. Both concepts, while possibly related, are not mutually exclusive. While a condition might not cause another underlying condition, it is possible that a condition aggravates the same underlying condition. The Board further finds that the examiner’s rationale does not appear supported by the evidence of record. In this regard, a review of the January 2020 VA examination shows the examiner cited a May 2014 VA medical record noting the Veteran took Excedrin daily, and that “medication overuse was suggested as a possible cause.” A review of that medical record shows the physician noted daily use of Excedrin, and that use of daily medication “could cause rebound headaches.” It was recommended that the Veteran wean himself off Excedrin. However, the examiner also noted a subsequent April 2015 VA examination which noted tension headaches and that Excedrin relieved his symptoms. The Board further notes that following the cited May 2014 VA medical record, a December 2014 VA medical record noted the Veteran had cut back on his consumption of Excedrin, and that he was able to manage his symptoms with 8 pills per week. See VA Medical Records Received November 2017. Additionally, a review of the April 2015 VA examination report shows the Veteran took Excedrin “about every other day” to treat his migraine headaches. A May 2016 VA medical record further noted that the Veteran experienced “good relief with Excedrin.” See VA Medical Records Received November 2017. Accordingly, medical records dating after the April 2014 VA medical record the examiner relied on for his rationale appear to directly contradict his findings; specifically, that daily use of Excedrin was the cause of the Veteran’s headaches. Finally, a more recent October 2020 VA medical record noted migraine headaches with a recent episode 2 days prior. The physician noted that the Veteran’s symptoms were better with over the counter Excedrin. The Veteran reported hydrating well and he agreed to change his medication to Naproxen. See VA Medical Records Received December 2020. The examiner did not address the conflicting medical evidence of record. Instead, the examiner simply stated that the Veteran’s headaches were “likely associated with overuse of headache medication.” Moreover, the examiner did not address the Veteran’s headache triggers as requested. In this regard, the Board notes the May 2016 VA medical record referred to above also notes headache triggers including stress, dehydration and lack of sleep. Psychiatric disorders noted included PTSD, insomnia and anxiety. The Veteran was advised to avoid known triggers. Additionally, a September 2017 VA psychiatric treatment record also shows the Veteran was advised to reduce stressors in his life. See VA Medical Records Received November 2017. For these reasons, the Board finds that a Remand is necessary to obtain a new VA examination report. The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Then, obtain an addendum by an appropriate examiner to determine the nature and etiology of his diagnosed headache condition. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed headache condition was caused by his service-connected PTSD, or medications used to treat his PTSD? Please explain why or why not. (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed headache condition was aggravated by service-connected PTSD, or medications used to treat his PTSD? Please explain why or why not. If the examiner finds that the disability was aggravated by the service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. The examiner should specifically address the Veteran’s headache triggers and whether they are related to his service-connected PTSD. The examiner is asked to consider the April 2015 VA examiner’s conclusion that the diagnosed headache condition was at least partially caused by the Veteran’s current level of stress as well as VA medical records noting headache triggers including stress, dehydration and lack of sleep. See May 2016 VA Medical Record. The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination, including this Remand. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Lamb, 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.