Citation Nr: 21028899 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-41 480 DATE: May 12, 2021 REMANDED Entitlement to service connection for a headache disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1997 to August 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in September 2014 by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2018 and September 2020, the Board remanded the claim on appeal for additional development and it now returns for further appellate review. Entitlement to service connection for a headache disorder. In the November 2018 remand, the Board noted that the Veteran's VA treatment records reflected complaints of headaches, and remanded the claim in order to afford him a VA examination so as to determine the nature and etiology of his claimed headache disorder, to include whether such is related to his military or his service-connected major depressive disorder. In January 2020, the Veteran underwent a VA examination, which was entitled Headache Disability Benefits Questionnaire (DBQ), at which time acute intermittent tension headaches were diagnosed. He also reported that his headaches first occurred during service in 1998, have worsened since 9/11, and currently occur twice a month. However, the examiner opined that the Veteran's claimed headache disorder was less likely than not related to his military service, or proximately due to, the result of, or aggravated by his service-connected major depressive disorder. However, in September 2020, the Board found that, as the examiner relied, in part, on a lack of complaints, treatment, or diagnosis of headaches in the Veteran's service treatment records in offering an unfavorable opinion and an August 2000 service treatment record reflected such a complaint, a remand was necessary in order to obtain an addendum opinion addressing such matter. However, a close review of the August 2000 service treatment record in fact reflects that there was no report of a headache; rather, it appears that the Board previously misinterpreted it. Nonetheless, the Board directed that a VA examiner offer an opinion as to whether it is at least as likely as not that a headache disorder had its onset during service or is otherwise related to service and determine whether there is an underlying disease or injury producing headaches or whether the Veteran has head pain without underlying pathology. In November 2020, a VA examiner review the record and opined that the Veteran's claimed headache disorder was less likely than not related to his military service. In this regard, she noted that there was no chronic diagnosis of headaches in the service or post-service treatment records. The examiner further found that the August 2000 service treatment record did not show headaches and post-service treatment records are silent for a chronic headache condition. In this regard, she indicated that instances of headaches through at least 2012 were associated with acute illness. The examiner also found that the lay statements were not supported by the evidence, and no DBQ pertaining to headaches was on file. However, as noted previously, a Headache DBQ was completed in January 2020 and it seems that the VA examiner only reviewed VA treatment records dated through 2012 when those dated through October 2020 are on file, which reflect an ongoing history of headaches and, as relevant, a complaint of headaches upon waking in connection with his service-connected obstructive sleep apnea (OSA) in November 2016. Furthermore, the November 2020 VA examiner did not address whether there was an underlying disease or injury producing headaches as requested in the September 2020 remand. See Stegall v. West, 11 Vet. App. 268 (1998). Thus, a remand is necessary in order to obtain another addendum opinion that addresses such matters. The matter is REMANDED for the following action: Return the record, to include a copy of this Remand, to the VA examiner who offered the November 2020 opinion regarding the etiology of the Veteran's headaches, or an appropriate substitute if she is unavailable. Following a review of the record, the examiner should address the following inquiries: (A) Identify all current headache disorders, to include intermittent tension headaches as diagnosed at the January 2020 VA examination. In this regard, the examiner should also determine whether there is an underlying disease or injury producing headaches or whether the Veteran has head pain without underlying pathology. (B) For each current headache disorder, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such had its onset in, or is otherwise related to, his military service. In offering such opinion, the examiner should consider the Veteran's report that his headaches had their onset in service in 1998, worsened since 9/11, and currently occurred twice a month as documented at the January 2020 VA examination. (C) For each current headache disorder, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such is caused or aggravated by the Veteran's OSA. For any aggravation found, the clinician should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology by the aggravation. In offering such opinion, the examiner should consider the Veteran's complaint of headaches upon waking in connection with his service-connected OSA in a November 2016 VA treatment record. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Koria B. Stanton, 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.