Citation Nr: 21030553 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-14 555 DATE: May 19, 2021 REMANDED Entitlement to service connection for trigeminal neuralgia, claimed as headaches, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1971 to May 1974, including service in Thailand. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), which, inter alia, denied service connection for trigeminal neuralgia, claimed as headaches. In January 2020, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This matter was previously before the Board in March 2020. At that time, the Board remanded the claim for further evidentiary development, to include an addendum medical opinion. Entitlement to service connection for trigeminal neuralgia, claimed as headaches, is remanded. The Veteran contends that he developed a headache disability as a result of his presumed exposure to herbicide agents and/or service-connected disabilities, including posttraumatic stress disorder (PTSD), ischemic cardiomyopathy, and chronic obstructive pulmonary disease (COPD). At the January 2020 Board hearing, noted above, the Veteran testified that he began to experience headaches while in Thailand, but self-treated with over-the-counter medication and tried to hide them. He noted that, when he returned to the United States following his service in Thailand, he experienced breathing difficulties coupled with headaches. Pursuant to the Board's March 2020 remand instructions, a VA medical opinion was obtained in September 2020. After review of the Veteran's claims file, the examiner rendered a negative etiological opinion regarding the Veteran's trigeminal neuralgia. The examiner opined in pertinent part, No documentation found in str regarding trigeminal neuralgia, nor treatments for headaches nor neuralgia as reported by Veteran during Dec 2014 C&P exam. April 17, 1974 report of medical history: no documentation of trigeminal neuralgia nor symptoms associated with trigeminal neuralgia. April 17, 1974 report of medical examination: no documentation of diagnosis of trigeminal neuralgia. No documentation found to support diagnosis of trigeminal neuralgia proximal to military discharge. Dec 2014 C&P exam, Veteran reported headaches began while serving in Thailand. He did not seek medical attention, however, self treated. The term at least as likely as not does not mean within the realm of possibility, but rather, it means that the weight of evidence both for and against a conclusion is so evenly divided that it is as sound to find in favor of that conclusion as it is to find against it. As noted above, SMRs [service medical records] are silent for evaluation of or treatment for trigeminal neuralgia. There is no medical evidence to support that Veteran's trigeminal neuralgia was caused by military service. Regarding secondary causation, the examiner opined in pertinent part, No clinical scientific research studies using appropriate research methodologies, large sample size which could be generalized which established a cause-and-effect relationship between trigeminal neuralgia [and] PTSD, ischemic cardiomyopathy and/or COPD. "Trigeminal neuralgia (TN) is characterized by recurrent brief episodes of unilateral electric shock-like pains, abrupt in onset and termination, in the distribution of one or more divisions of the fifth cranial (trigeminal) nerve that typically are triggered by innocuous stimuli. Compression of the trigeminal nerve root is the main mechanism of TN, but brainstem lesions account for a small proportion of cases. Most cases of TN are caused by compression of the trigeminal nerve root. Demyelination of one or more of the trigeminal nerve nuclei may also be caused by multiple sclerosis, tumors located at the cerebellopontine angle, or other structural lesions of the brainstem." With regard to aggravation, the examiner concluded, Trigeminal neuralgia is usually caused by pressure on trigeminal nerve, causing it to malfunction. Triggers for aggravating trigeminal neuralgia include: shaving, eating, touching face, drinking, brushing teeth, tactile stimulation of facial trigger zones. Neither PTSD, ischemic cardiomyopathy nor COPD cause compression of trigeminal nerve that would result in aggravation of trigeminal neuralgia. An additional VA medical opinion was obtained in October 2020. After review of the Veteran's claims file, the examiner rendered a negative etiological opinion regarding the Veteran's trigeminal neuralgia. The examiner opined in pertinent part, No clinical scientific research studies using appropriate research methodologies, large sample size which could be generalized which established a cause-and-effect relationship between trigeminal neuralgia [and] Agent Orange exposure. Mayo Clinic article presented by Veteran does not document Agent Orange as being a cause of trigeminal neuralgia. Trigeminal neuralgia is not recognized as presumptive condition associated with Agent Orange exposure. There is no medical evidence to support that Veteran's trigeminal neuralgia was caused by Agent Orange exposure. The Board finds that the opinions are inadequate. In that regard, although the examiner noted the Veteran's reports that he began to experience headaches in Thailand but self-treated and did not seek medical attention, she did not appear to consider these reports or the Veteran's hearing testimony regarding continuity of symptomatology in rendering her opinion. In addition, the Board finds that the examiner's rationale regarding aggravation is inadequate, as she appears to conflate secondary causation with aggravation. While the Board greatly regrets further delay, remand is required for an additional medical opinion for full compliance with the Board's previous remand instructions. Stegall v. West, 11 Vet. App. 268, 270-71 (1998). Accordingly, the matter is REMANDED for the following action: 1. Obtain an addendum opinion as to the nature and etiology of the Veteran's diagnosed trigeminal neuralgia, claimed as headaches. The claims file must be made available to the clinician rendering the requested opinion. After reviewing the claims file, the examiner should opine as to the following: Is it at least as likely as not that trigeminal neuralgia had its onset in service or is otherwise related to the Veteran's active service, to include presumed exposure to herbicide agents? If not, is it at least as likely as not that trigeminal neuralgia was proximately due to or the result of the Veteran's service-connected (a) PTSD; (b) ischemic cardiomyopathy; and/or (c) COPD? If neither, is it at least as likely as not that trigeminal neuralgia was aggravated (permanently made worse) by the Veteran's service-connected (a) PTSD; (b) ischemic cardiomyopathy; and/or (c) COPD? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. In providing the requested opinions, the clinician should review the relevant evidence of record, to include (a) the December 2014 VA examination report; (b) the Veteran's January 2020 testimony that he began to experience headaches in Thailand but self-treated, experienced headaches coupled with breathing difficulties when he returned to the United States, and has since continued to experience headaches; and (c) an article from the Mayo Clinic submitted by the Veteran in January 2017 regarding the causes of trigeminal neuralgia. The opinion must take into consideration the Veteran's lay statements and be supported with a rationale. In providing the requested opinion, the clinician should consider the Veteran's description of his in-service and post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? If the clinician determines that an examination of the Veteran is necessary, one should be scheduled. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Ruddy, 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.