Citation Nr: 21024877 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 15-26 162 DATE: April 26, 2021 REMANDED Entitlement to service connection for migraine headaches is remanded. REASONS FOR REMAND The Veteran served in the United States Navy from August 1971 to October 1973. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 rating decision. During the pendency of this claim, in March 2020, the Veteran passed away. The Veteran’s surviving spouse requested to be substituted in the claim for service connection and has been properly substituted by the Agency of Original Jurisdiction (AOJ) as the Appellant. 38 U.S.C. § 101(3). The matter was most recently before the Board in August 2020, when it was remanded to the AOJ for issuance of a Supplemental Statement of the Case (SSOC), which was issued in January 2021. As such, the directives have been substantially complied with and the appeal is again properly before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). In August 2020 the Board also remanded the issue of entitlement to service connection for a psychiatric disability. While on remand, service connection for a psychiatric disability was granted in a rating decision issued in January 2021. As this constitutes a full grant of the benefits sought on appeal, that issue is no longer part of the current appeal. Ab v. Brown, 6 Vet. App. 35 (1993). Entitlement to service connection for migraine headaches. A Veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service. 38 U.S.C. § 1111. When no pre-existing condition is noted upon entry, the Veteran is presumed to have been sound upon entry and the presumption of soundness arises. If the presumption of soundness applies, to rebut the presumption of soundness under 38 U.S.C. § 1111, VA must show by clear and unmistakable evidence (i.e. undebatable) both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA’s duty under the second prong of this rebuttal standard attaches. VA Gen. Coun. Prec. 3-2003 (July 16, 2003); see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). If the government fails to rebut the presumption of soundness, the claim is one for service connection, not aggravation. Id. at 1096. In this case, the Veteran’s service entrance examination did not note any headache disorder. Additionally, the Veteran denied any current or history of frequent or severe headaches at that time. See July 1971 Report of Medical History. The record reflects that the Veteran reported headaches at times behind his eyes and in the temples after leaving the service. See June 1974 VA examination report. The record reflects that the Veteran was first seen by neurology in December 1986 and that it was documented that he had headaches intermittently since childhood, he was currently having headaches almost every day, and his family history was significant in that his mother was afflicted with migraine. See December 1986 VA medical record consultation sheet; see also January 1998 VA examination report. During a September 2003 neurology consult, the Veteran reported that he had experienced migraines since the age of 25, twice daily, every day. See September 2003 VA treatment records. The Veteran contended that he suffered from chronic severe “cluster” migraine headaches, that he had his first one during service, and that he had these migraines ever since he was in the Navy stationed with the Marines. See December 2012 correspondence. The Veteran’s examination upon entrance into service in July 1971 notes no pre-existing headache disability; therefore, the presumption of soundness attaches. 38 U.S.C. § 1111. Given the evidence above indicating that the Veteran’s headaches began when he was a child, a medical opinion should be obtained on remand addressing whether such disability was aggravated during service. Wagner, 370 F.3d 1089. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate professional addressing the etiology of the Veteran’s migraine headaches. The examiner should address the following questions: (a) Is it clear and unmistakable (i.e. undebatable) that the Veteran’s headache disability pre-existed his period of active service? Attention is invited to the VA treatment notes indicating the presence of headaches since childhood. (b) If so, is it clear and unmistakable (i.e. undebatable) that the Veteran’s pre-existing headache disability was NOT aggravated beyond its natural progression during his period of active service? (c) If the answer to either (a) or (b) is no, is it at least as likely as not (a fifty percent probability or greater) that the headache disability is causally related to the Veteran’s active service? A complete rationale, supported by sound medical reasoning, must be provided for all opinions provided. CHRISTOPHER A. WENDELL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Fulmer, Associate 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.