Citation Nr: 21027504 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 17-15 355 DATE: May 5, 2021 REMANDED Entitlement to service connection for migraines, claimed as due to environmental hazards while serving in the Persian Gulf War, to include as secondary to the Veteran's service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1998 to October 1998 and from January 2004 to March 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a December 2014 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in September 3019, at which time the Board reopened the claim based on the submission of new and material evidence but denied the claim on the merits. The Veteran timely appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In September 2020, the Court granted the parties Joint Motion for Partial Remand (JMPR), in which the parties agreed the April 2017 VA examination opinion was inadequate because it failed to adequately address the issue of aggravation consistent with the Court's decision in Ward v. Wilkie, 31 Vet. App. 233 (2019),where the Court ruled that an opinion on aggravation must include whether there is any incremental increase in disability in the nonservice-connected disabilities resulting from the service-connected conditions, above the degree of disability existing before the increase.. Thus, an addendum opinion addressing aggravation in accordance with eh holding in Ward was ordered. In its January 2021 decision, the Board remanded this matter in order to comply with the Court's order and the JMPR. This matter has since returned to the Board for further appellate review. 1. Entitlement to service connection for migraines, claimed as due to environmental hazards while serving in the Persian Gulf War, to include as secondary to the Veteran's service-connected posttraumatic stress disorder (PTSD), is remanded. An addendum medical opinion was provided in February 2021. This examiner opined there is no evidence of any aggravation or worsening of the Veteran's migraine headaches beyond the normal disease progression by the Veteran's service-connected PTSD. The examiner noted the Veteran's past treatment visits and examinations concerning her PTSD and/or her migraine headaches, addressing these visits and noting whether or not the Veteran complained of migraine headaches. In March 2021, the Veteran submitted a written statement along with private treatment records from Dr. M.A., to whom the VAMC outsourced her treatment. In her letter, the Veteran indicated that Dr. M.A. told her to see her psychiatrist to manage her PTSD because it does and can affect her migraines and headaches. She stated he explained that PTSD interferes with a person's life as far as relationships and work, and this causes stress, which can increase the likelihood of headaches. The Veteran described that the day of her appointment she was having a very difficult time with her PTSD due to nightmares. Dr. M.A. also explained to the Veteran that she had two different types of headaches, chronic migraines associated with her Chiari Malformation, as well as tension-type headaches associated with her PTSD. In his March 2021 treatment note, Dr. M.A. diagnosed the Veteran with both chronic migraines as well as tension-type headaches. He noted the Veteran had a history of both chronic migraines as well as PTSD and Chiari malformation, status post surgery, with increasing headaches that seemed to be mixed, with chronic muscle contraction tension-type headaches along with the migraines. He further noted the Veteran's chronic tension-type headaches seem predominately muscle contraction tension-type headaches, and suggested she keep her follow-up appointment with her psychiatrist because her medication may need to be adjusted due to her recent increased stress. Dr. M.A.'s treatment notes, along with the statements the Veteran reported Dr. M.A. made to her during her appointment, indicate that at least one, if not both, of her diagnosed headache conditions may be impacted by her PTSD. However, while Dr. M.A. alludes to such in his treatment notes, he did not provide a nexus opinion on the matter. Additionally, even though the Veteran is competent to report the statements Dr. M.A. made to her during her appointment, she is not competent to provide a nexus opinion on the etiology of her headaches because she lacks the requisite medical training and expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377n.4 (Fed. Cir. 2007). However, the Veteran has reasonably raised the possibility that her tension-type headaches may be aggravated by her service-connected PTSD. Although the February 2021 examiner opined on whether the Veteran's PTSD aggravated her migraine headaches, the examiner did not opine on whether her PTSD aggravated her tension-type headaches. As such, the Board finds an addendum opinion is necessary to address this theory of aggravation. Accordingly, the matter is REMANDED for the following action: Obtain an addendum opinion from a qualified medical professional to determine the etiology of the Veteran's migraines and tension headaches. The entire claims file, including this remand, must be made available to the examiner. The need for further examination or a telehealth interview is left to the discretion of the examiner. The examiner must offer an opinion as to the following: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's migraines and/or tension headaches were aggravated by (i.e., incrementally increased in severity beyond a natural progression by) the Veteran's service-connected PTSD? The examiner is to address the Veteran's lay statements concerning her migraines and tension headaches, including as related to her PTSD and treatment thereof, as well as the March 2021 treatment notes from Dr. M.A. indicating the Veteran's PTSD may aggravate her migraines and/or tension headaches. A complete rationale for all opinions must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, the examiner must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. M. Mills Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gabrielle Ongies, 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.