Citation Nr: 21026989 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 15-41 418 DATE: May 4, 2021 REMANDED The issue of entitlement to service connection for a sleep disorder, to include sleep apnea, secondary to service-connected occipital headaches, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1966 to October 1968. These matters come to the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. Jurisdiction was subsequently transferred to the RO in Columbia, South Carolina. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in October 2018. The transcript of the hearing has been associated with the claims file. This matter was previously before the Board at which times it was remanded for further development. Entitlement to service connection for a sleep disorder, to include sleep apnea, secondary to service-connected occipital headaches is remanded. The Veteran contends that he has a sleep disorder secondary to his service-connected occipital headaches. In this regard, the evidence of record includes a January 2020 VA examination report in which an examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner also opined that the sleep condition had not been permanently worsened beyond normal progression (aggravated) by a service-connected disability. The examiner reasoned that the Veteran reported that his headaches began during service and his sleep problems began after his discharge. The Veteran stated that he was stressed after his graduation from college and worried about his ability to provide for his family. He indicated that currently he was able to initiate sleep but that he woke up several times per night. His sleep issues occurred two to three times per week. The examiner determined that there was no indication that the Veteran's sleep issues were associated with his headaches or his military service. In June 2020 the Board remanded the Veteran's claim to obtain a sufficient rationale considering the Veteran's competent lay testimony. Subsequently, in a March 2021 VA examination report, an examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected headaches. The examiner also opined that it was less likely than not that the Veteran's sleep disorder was aggravated (worsened beyond normal progression) by his occipital headaches. The examiner observed that the Veteran was claiming that his REM sleep disorder was caused by headaches; however, according to research, the sleep deprivation caused by REM sleep disorder will precipitate headaches. Per Weintraub, migraine headaches usually occur either during or after REM sleep or in delta sleep which is the deep sleep that we all require in order to feel alert and refreshed the following day. Based on current research, it remains unclear whether the changes in the neurotransmitter or chemical systems in the brain, hormonal influences, or a combination of several different phenomenon are the cause of migraine headaches. From experiments in the 1950s it was discovered that people who were REM sleep deprived were more likely to develop some underlying psychiatric or depressive illness with or without headaches. It is suspected that certain chemicals in the brain not only play a role in the mechanism of migraine but also predispose people to awaken from REM sleep with a headache. Since decreased oxygen and transient hypertension are noted to occur with sleep apnea, it has been suggested that these factors can trigger early morning headaches. These headaches are typically located in the frontal areas but can be diffuse involving the entire head. The Board finds the March 2021 VA examiner opinion inadequate to decide the Veteran's claim for a sleep disorder. The examiner based his opinion on research involving migraine headaches. However, the Board notes that the Veteran is service connected for occipital headaches, not migraine headaches. Therefore, clarification in the form of an addendum opinion addressing whether the Veteran has a sleep disorder secondary to service-connected occipital headaches, should be obtained on remand. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate) The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment that have not yet been associated with the claims file, and associate with the claims file any outstanding VA treatment records. 2. Return the record to the March 2021 VA examiner. The record and a copy of this Remand must be made available to the examiner. If the examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. (a.) Is it at least as likely as not that the Veteran has a sleep disorder that was caused or aggravated (worsened beyond normal progression) by his service-connected occipital headaches? The examiner is asked to address both causation and aggravation. The examiner is asked to specifically discuss the Veteran's October 2018 Board testimony regarding difficulty sleeping related to his service-connected occipital headaches. (b.) Please note that the Veteran is service connected for occipital headaches not migraine headaches. (c.) If the examiner finds that the Veteran's sleep disorder has been worsened beyond normal progression (aggravated) by the Veteran's service-connected occipital headaches, the examiner should attempt to quantify the degree of aggravation beyond the baseline level that is attributed to the service-connected disability. All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith-Jennings, 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.