Citation Nr: 21032751 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 19-28 729 DATE: May 27, 2021 ORDER Entitlement to service connection for headaches is denied. FINDING OF FACT The Veteran's headaches are not secondary to service-connected hypertensive vascular disease, and are not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for headaches due to service or a service-connected disease or injury are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1966 to September 1968, and from March 1982 to March 2000. This matter is before the Board of Veterans' Appeals (Board) on appeal from a November 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The issue on appeal was previously before the Board in June 2020, November 2020, and February 2021, and remanded for further development. There has been substantial compliance with its previous remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). REASONS AND BASES FOR FINDING AND CONCLUSION 1. Entitlement to service connection for headaches is denied. The Veteran contends that his headaches began during active service in the 1980s. See November 2018 VA examination. A secondary theory of entitlement was included during the pendency of the claim. See October 2018 exam request. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that is proximately due to or aggravated by a service-connected disability, or is otherwise related to an in-service injury, event, or disease. In an August 1996 report of medical history, the Veteran denied frequent or severe headaches, but noted he has or has had dizziness or fainting spells. His August 1966 entrance exam noted a normal clinical evaluation of the neurologic system and the head, face, neck, and scalp. An October 1966 service treatment record (STR) noted complaints of headaches, dizziness, sore throat, cough, and temperature of 98 degrees. The clinician noted "Flu: headaches, dizziness," and medication was prescribed. An August 1967 STR noted complaints of dizzy spells and loss of balance. The Veteran reported he has cold chills at night. He was advised to take salt tabs daily. A November 1966 STR noted complaints of headaches and dizziness for 4 days, and temperature of 99 degrees. The clinician noted "Tension headache." An August 1968 report of examination reflects a normal clinical evaluation of the neurologic system and the head, face, neck, and scalp. In his December 1981 report of medical history, the Veteran denied frequent or severe headaches, or dizziness or fainting spells. A December 1981 report of examination reflects a normal clinical evaluation of the neurologic system and the head, face, neck, and scalp. An October 1982 STR noted a complaint of headaches for 24 hours. The assessment was "possible stress H/A [headaches]." A December 1982 STR noted complaints of headaches and sinus pressure. The assessment was upper respiratory infection (URI). A June 1987 report of examination noted a normal clinical evaluation of the neurologic system and the head, face, neck, and scalp. In a September 1988 report of medical history, the Veteran denied frequent or severe headaches, or dizziness or fainting spells. A September 1988 report of examination noted a normal clinical evaluation of the neurologic system and the head, face, neck, and scalp. In a March 1992 STR, the Veteran reported sudden onset of lightheadedness after arising from sitting. The assessment was mild orthostatic event with no apparent sequelae. In a May 1993 report of medical history, the Veteran denied frequent or severe headaches, or dizziness or fainting spells. A May 1993 report of examination noted a normal clinical evaluation of the neurologic system and the head, face, neck, and scalp. His January 2000 retirement examination noted a normal clinical evaluation of the neurologic system and the head, face, neck, and scalp. Post-service, a July 2011 private record noted complaints of headaches, chest congestion, and cough for 4 days. The plan note wrote, "URI: Z pack, Tessalon Perles." A January 2013 private record noted cough and congestion for 5 days, headache, fatigue, and fever. The assessment was URI. A February 2013 private record noted that the Veteran was having scratchy throat, headache, sneezing, and sinus congestion. The Veteran was recommended to restart Flonase. A March 2015 private record noted the Veteran fell off a ladder, landing on his back and hitting the back of his head. It noted that the Veteran became altered afterwards and was brought to emergency room. The CT scan revealed that he sustained a small subarachnoid hemorrhage and subdural hematoma. He also had a concussion. A September 2015 private record noted the Veteran reported for hypertension, and that he started getting headaches. The clinician increased the medication for hypertension, made a notation of "headache: related to elevated BP," and requested a follow-up visit in one week. A follow-up record the week after noted "no further complaints," and notes regarding headaches were not shown. Further records from this provider including two consecutive follow-up visits in March and October 2016 did not reveal any complaints of headaches. In a September 2017 VA record, the Veteran denied headaches, focal weakness, or sensory loss. In an October 2017 private sleep study, the Veteran denied headaches. In a November 2017 VA ophthalmology record, past medical history of pertinence noted "no migraines." In a January 2018 private record, the Veteran denied headaches. In an April 2018 private record, the review of systems noted no headaches. A September 2018 VA record noted the Veteran denied headaches, focal weakness, no sensation loss The Veteran underwent a VA contract examination in October 2018. The Veteran was diagnosed with migraine including migraine variants. The Veteran reported that he randomly started getting frequent headaches. He stated that he thought it was seasonal allergies, but medication for allergies did not help. He stated he experienced a fall in April 2015 where he hit his head and developed hematoma. He stated his headaches have become more frequent and intense, and that he has to lay down at times. He stated he takes Tylenol Extra Strength for the headaches. He reported pain on both sides of the head, but without symptoms such as nausea, vomiting, sensitivity to light or sound, changes in vision, or sensory changes. The examiner noted that he performed an in-person examination and that he has reviewed the VA e-folder. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that, during service, the Veteran's headache condition was acute only. He noted that there is no evidence of chronicity of care. He concluded that a nexus has not been established. The examiner also opined that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected hypertensive vascular disease. He explained that the claimed disorder is a separate entity entirely from the service-connected condition and unrelated to it. He also noted that the medical literature does not support a medical relationship, and that a nexus has not been established. In an October 2018 private treatment record, the Veteran denied headaches. The Veteran underwent a VA examination in November 2018. The examiner noted "yes" for the question whether the Veteran has or has ever been diagnosed with a headache condition, but further elaborated in the remarks that he did not have a diagnosis. The Veteran reported he has had intermittent headaches since the early 1980s, and that its features have not changed since. He stated the head pain is located in the frontal or posterior head region on both sides. He stated that he is in bed for hours when he has the headaches. He has identified no triggers for his headache episodes. The examiner noted excerpts of STRs and VA treatment records related to headaches, including September 2017 and September 2018 VA records in which the Veteran denied headaches. The examiner also noted a portion of the October 2018 exam that described a head injury with subdural hematoma in 2015. The examiner noted in the remarks that while a diagnosis of a headache condition depends entirely on reported history, when the reported lay statements are not supported by clinical records, treatment records should be utilized to determine a diagnosis. The examiner noted that as the Veteran's STRs nor medical records are inconsistent with a chronic headache condition, there was no diagnosis of a chronic headache condition. The examiner added that there is no diagnosis because there is no pathology on which to render a diagnosis of headaches. The examiner also noted that, if it was stipulated that the Veteran has migraines for the purpose of this opinion, it should be noted that his headache pattern changed after he sustained the head injury in 2015. The examiner noted that the headache pattern described from the 2015 head injury differed from that which was noted in service. He noted that if the Veteran's statements that he has to lie down when he has headaches because they are so severe were true, then his current headaches are more likely than not the result of the 2015 head trauma with subdural hematoma. The examiner further noted that, if the headaches did exist and were due to hypertension, then they should resolve once hypertension is controlled. He noted that the Veteran has had controlled blood pressure in the VA clinic where he reported no headaches. The examiner concluded that, from his perspective, there is no diagnosis of headaches because there is no pathology on which to render such a diagnosis. He added that even if benefit of the doubt was resolved in the Veteran's favor and a diagnosis of migraine is recognized as did by the October 2018 examiner, his migraine headaches are less likely than not incurred in or caused by his hypertension. VA and private treatment records from 2018 to 2020 consistently show that the Veteran denied headaches. In his December 2018 and January 2019 private treatment records, the Veteran denied headaches. In a September 2019 VA medical record, he denied headaches. In his October 2019, February 2020, and April 2020 private treatment records, the Veteran denied headaches. In November 2020, the Board remanded the appeal upon finding the October 2018 VA opinion was inadequate as it related to secondary service connection. In December 2020, an addendum VA opinion was received. The examiner opined that the Veteran's claimed condition was not caused or aggravated his hypertensive vascular disease. The examiner noted that while the October 2018 exam noted a diagnosis of migraines, the available records do not reveal medical evaluations, consistent treatments, or a diagnosis of a chronic headache condition. She noted that the Veteran reported only intermittent headaches that did not change in its condition since the 1980s. She noted that while the Veteran is competent to provide a history of symptoms, he is not capable of diagnosing a medical condition as related to those symptoms. The examiner concluded that there is lack of medical evidence confirming that the Veteran's headaches are due to or the result of, or permanently aggravated beyond normal progression by his hypertensive vascular disease. She concluded that a nexus has not been established. In February 2021, the Board remanded the appeal because the December 2020 VA opinions contained inadequacies. The examination form used the pre-existing conditions standard incorrectly instead of the secondary-service connection standard and the aggravation opinion included the incorrect standard of "permanent" aggravation. Finally, the examiner acknowledged considering the Veteran's lay testimony, but did not explain why she discounted it. In March 2021, another addendum VA opinion was received. The examiner first noted that there is conflicting evidence as to the diagnosis of the two exams in 2018. He noted that migraine headaches were diagnosed at the October 2018 examination, and simple headache was diagnosed at the November 2018 examination. He commented that there is nothing to suggest a diagnosis of migraines as no pulsating component was noted. He explained that while not all pulsation associated with headaches is due to migraines, almost all migraines are associated with a pulsating component. He noted that, regardless of the diagnosis, neither is due to the Veteran's hypertension. He noted that the Veteran has an essential hypertension, and has been on single-dose medication with relatively good blood pressure control. He explained that headaches are generally not associated with hypertension, especially with well-controlled hypertension. He noted this was established medical knowledge and practice based on medical literature. He noted exceptions include hypertensive crises, but that there was no evidence of such. He added that there are no other documentation connecting headaches to hypertension as to its onset or medical events. The examiner concluded that it is less likely than not that the Veteran's headaches are due to his hypertension. The examiner also noted that there was no evidence of aggravation of the Veteran's headaches beyond the natural course. He explained that headache conditions commonly have variable presentations, and tend to worsen with time and aging. He concluded that it is less likely than not that the Veteran's headache condition has been aggravated beyond its natural course due to any cause, including his hypertension. After a careful review of the record, the Board finds the preponderance of the evidence weighs against entitlement to service connection for headaches on a direct or secondary basis. The evidence of record weighs against finding that the Veteran's headaches onset in service or are related to service. The Veteran's STRs include intermittent reports of headaches. Some were symptoms of flu, URI, or an orthostatic event, and only a very few reports of tension headaches or stress headaches appear over a time span of 20 years of active service. Indeed, the Veteran consistently denied any frequent or severe headaches throughout those years of active service, including at separation, and the reports of examinations consistently noted a normal clinical evaluation of the neurologic system and the head, face, neck, and scalp. Moreover, VA medical opinions establish that the Veteran's headaches are not at least as likely as not related to active service. The October 2018 examiner explained that the headache condition was acute only during service, and without any evidence of chronicity of care. The November 2018 examiner noted that the headache pattern currently described differed from that in service, and that the currently described headaches were more likely than not the result of the 2015 head trauma with subdural hematoma. He also noted that the Veteran's medical treatment records, especially the recent VA treatment records, did not support a chronic headache condition. The examiners' combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The evidence of record also weighs against finding that the Veteran's headaches are caused or aggravated by his hypertensive vascular disease. The November 2018 examiner explained that the Veteran's headache pattern changed after he sustained a head injury with subdural hematoma, and was rather the result of the head trauma with subdural hematoma. The examiner also noted that if headaches are claimed secondary to hypertension, then the headaches should resolve once hypertension is controlled, which was indeed shown by the Veteran's VA records. The March 2021 examiner explained that headaches are generally not associated with hypertension, especially with well-controlled hypertension, as was the case for the Veteran. He also noted that headache conditions typically have variable presentations, and tend to worsen with time and aging. The examiners' combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. The Veteran believes his headaches are related to service, or are otherwise caused or aggravated by his service-connected hypertensive vascular disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the medical examiners' opinions of record. For the reasons stated above, the Board finds that the preponderance of evidence is against the Veteran's claim of entitlement to service connection for headaches. There is no reasonable doubt to be resolved. Service connection for headaches is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jake Choi, 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.