Citation Nr: 21039746 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 17-67 113 DATE: July 1, 2021 REMANDED Entitlement to service connection for a headache disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1983 to June 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in April 2016 by a Department of Veterans Affairs (VA) Regional Office. In May 2019 and July 2020, the Board remanded the instant claim and it now returns for further appellate review. The Board observes that since the issuance of the July 2020 supplemental statement of the case, additional evidence was associated with the record. However, as the Veteran's claim is being remanded, the Agency of Original Jurisdiction (AOJ) will have an opportunity to review the newly received evidence such that no prejudice results to the Veteran in the Board considering such evidence for the limited purpose of issuing a comprehensive and thorough remand. Entitlement to service connection for a headache disorder is remanded. The Board finds that this issue must be remanded for a new VA opinion. The Veteran asserts he first experienced symptoms associated with a headache disorder during active duty service. In this regard, service treatment records (STRs) reflect that the Veteran complained of headaches on several occasions. Specifically, a December 1983 STR reflects the Veteran's complaint of headache, which was associated with an assessment of viral gastroenteritis. A June 1986 STR reveals the Veteran's complaint of headache, which was associated with an assessment of allergic rhinitis. A July 1986 STR notes the Veteran's complaint of sore throat, coughing, vomiting, nausea, and headache for the previous two to three days. A December 1986 STR shows his complaint of throbbing headache with dizziness, which was associated with other symptoms diagnosed as upper respiratory infection. The Veteran's April 1987 separation examination reflects that his head and neurological examinations were normal, and the corresponding Report of Medical History demonstrates that he denied frequent or severe headaches. The Veteran's post-service treatment records include his complaints of headaches. In this regard, in September 1992, the Veteran reported that he had headaches with substance use. An undated VA treatment record reflects that the Veteran was requesting detox for substance abuse, and complained of a headache that day. In July 1999, the Veteran reported that he was experiencing massive headaches. In November 1999, the Veteran indicated that he had daily headaches in the back of his head. An August 2000 VA treatment record reveals that the Veteran went to the emergency room with a headache which had lasted two hours. A November 2008 VA treatment record notes the Veteran's complaint of nausea, diarrhea, headache, and productive cough. A March 2014 VA treatment record reflects the Veteran's complaint of sinus pressure, nasal congestion, headache, and dizziness. A March 2016 VA treatment record reveals the Veteran's report of increased migraines since using his CPAP machine. In April 2016and June 2017, the Veteran complained of a headache. At both times, he reported experiencing headaches since 1986; a diagnosis of chronic daily headache was made. A July 2017 VA treatment record reveals the Veteran's report of daily headaches at the top of his head. VA treatment records dated in December 2017 and December 2018 note the Veteran's history of chronic headaches. Additionally, VA treatment records dated in 2019 include "chronic headache disorder" in his current problems list. In connection with his current claim the Veteran underwent a VA examination in April 2016. The examiner found that the Veteran was not then, and never had been, diagnosed with a headache condition. The examiner did not give an opinion on etiology. The Veteran was afforded another VA examination in October 2020. At such time, a diagnosis of migraine headaches was made. In this regard, the examiner opined that such disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support thereof, the examiner reported that, although there was an April 2019 letter from the Veteran's representative indicating that the Veteran had service medical records of headaches while on active duty and the Veteran had sworn statements of his headaches, such records were not located in the Veteran's claims file. The Board find that this opinion is not adequate. The VA examiner only cited an April 2019 letter from an attorney and sworn statements from the Veteran, neither of which the examiner could locate in the file. The examiner's inability to locate this information calls into question the thoroughness and accuracy of examiner's file review. Moreover, even if the examiner did not find this documentation, the examiner did not explain why documentation was needed in light of the Veteran's lay reports. See McKinney v. McDonald, 28 Vet. App. 15, 30 (2016); Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015); Buczynski v. Shinseki, 24 Vet. App. 221, 223-24 (2011). Also significant, the examiner did not cite or discuss the considerable other evidence in the file pertaining to his headaches, as indicated. Thus, the examiner's opinion appears to be based on an incomplete factual history. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Furthermore, the Veteran recently advanced a new theory of entitlement in that his headache disorder is caused and/or aggravated by his service-connected posttraumatic stress disorder (PTSD). In this regard, in an October 2020 written correspondence, the Veteran indicated that, while in service, he was physically and sexually assaulted, which resulted in severe PTSD; and that he experienced extremely painful migraines associated with his PTSD. Additionally, a September 2020 written correspondence from a parent, J.W., indicates that any incident of the Veteran's PTSD was always accompanied by a severe migraine. An October 2020 written correspondence from his wife, S.W., reflects that they were unable to make plans as his headaches were so frequent and unpredictable, and were linked to the stress of his PTSD. Further, a February 2019 private treatment reflects a notation of frequent headaches with "[t]ension headaches and also may be related to pain and psychiatric issues and stress." Thus, the Board finds that a remand is necessary to obtain an addendum opinion that addresses such matters. The matters are REMANDED for the following action: After undertaking any preliminary development needed, arrange for the relevant information in the Veteran's claims folder to be returned to the examiner who conducted the prior VA examination (or a suitable substitute if such examiner is unavailable), for the purpose of preparing an addendum opinion regarding the claimed headache condition. (The need for an additional in-person examination should be determined by the examiner.) Following a full review of the record, the examiner should provide an opinion on the following: (a.) Is it at least as likely as not that the Veteran's headache disorder had its onset in, or is otherwise related to, his service? In offering such opinion, the examiner must consider the December 1983, June 1986, July 1986, and December 1986 STRs reflecting the Veteran's complaints of headaches. (b.) Whether the current condition is at least as likely as not (1) proximately due to a different medical condition, or (2) aggravated beyond its natural progression by a different medical condition, especially PTSD. If so, the examiner is asked to identify the primary medical condition. In offering such opinion, the examiner must consider the September and October 2020 lay statements by the Veteran, his father, and his wife (as described above); and the February 2019 private treatment record reflecting that the Veteran's tension headaches may be related to pain, psychiatric issues, and stress. (Continued on the next page) As indicated, in answering all questions, the examiner is asked to consider the statements from the Veteran, his wife, and his parent regarding the history and circumstances of his headaches. The examiner is asked to explain why their statements make it more or less likely that a current condition is related to service or PTSD. If indicated, it should be explained whether there is a **medical** reason to believe that the Veteran's recollection of his symptoms during and after service may be inaccurate or not medically supported as the onset or cause of his current diagnosis. The examiner should not rely on silence in the medical records unless it can be explained: (a) why the silence in the available records can be taken as proof that the symptom(s) did not occur, including why the fact would have normally been recorded if present, or (b) why the absence of medical records is medically significant. Corey Bosely Acting 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.