Citation Nr: 21039862 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 16-52 289 DATE: July 1, 2021 ORDER Entitlement to service connection for migraine headaches, secondary to service-connected posttraumatic stress disorder (PTSD), on a causation basis, is granted. Entitlement to service connection for sleep apnea, secondary to service-connected PTSD on a causation basis, is granted. FINDINGS OF FACT 1. The preponderance of the evidence is in favor of a finding that the Veteran's migraine headaches are caused by his service-connected PTSD. 2. The preponderance of the evidence is in favor of a finding that the Veteran's sleep apnea is caused by his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for migraine headaches, secondary to service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 113; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310(b). 2. The criteria for service connection for sleep apnea, secondary to service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310(b). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Navy from June 1981 to June 1983. These matters come to the Board of Veterans' Appeals (Board) on appeal from July 2016 and June 2017 rating decisions that denied service connection for headaches and sleep apnea, respectively. The Board remanded these claims in January and April 2019. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Veteran contends that his headaches and sleep apnea are due to his service-connected PTSD. In that regard, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Headaches The Veteran contends that his headaches are a result of his service-connected PTSD. The Veteran was diagnosed with migraine headaches in a February 2016 psych note, diagnosed again in a June 2016 VA examination, and a history of migraine headaches was shown as early as a June 1997 hospital report. Therefore, the current disability element has been established. Additionally, the Veteran was service-connected for PTSD in a March 2020 rating decision, thereby establishing the service-connected disability element of secondary service connection. The dispositive issue remaining is whether the Veteran's headaches are related to his now service-connected PTSD. To that end, the Veteran a private physician prepared a disability benefits questionnaire, providing a positive medical opinion, concluding it is as likely as not that the Veteran's chronic headache pain began during his time in service and is precipitated and aggravated by his major depressive symptoms. The private physician indicated that research shows anxiety and depression facilitate the onset of headaches and patients with chronic headache pain present with high levels of anxiety and depressive symptomology. The physician's opinion is supported by a review of the Veteran's claims file and an interview of the Veteran where he stated an increase in his mental health symptoms will bring on headache pain or exacerbate existing headaches and he experiences approximately 4-5 headaches per week associated with an escalation of mental health symptoms. As the private physician cited and applied relevant medical literature, reviewed the Veteran's claims file, examined the Veteran, and provided a thorough rationale, the positive medical opinion is afforded substantial probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The above evidence reflects that there is a competent, probative medical opinion that weighs in favor of service connection for the Veteran's headaches secondary to his service-connected PTSD, and no probative evidence against. The preponderance of the evidence is therefore in support of the claim for entitlement to service connection for headaches secondary to service-connected PTSD on a causation basis, and the claim must be granted. Sleep Apnea The Veteran contends that his sleep apnea is a result of his service-connected PTSD. During a June 2013 PTSD consult, a diagnosis of obstructive sleep apnea was noted. A September 2013 hematology/oncology note also showed a diagnosis of obstructive sleep apnea and the prescription of a C-PAP machine for use at night when he snores in his sleep. It was also reported that the Veteran was diagnosed with sleep apnea and prescribed C-PAP therapy as early as a September 2009 sleep study. Therefore, the current disability element is satisfied. As noted in the prior section, the Veteran's PTSD was service connected in a March 2020 rating decision, thereby establishing the second element of secondary service connection. The dispositive issue is therefore whether the Veteran's sleep apnea is related to his service-connected PTSD. To that end, the private physician in January 2018 also provided a positive medical opinion on this question, concluding that based on his experience, interview with the Veteran, review of the medical records and the supporting literature, it is as likely as not that the Veteran's depression symptoms and sedating medications aided in the development of and permanently aggravates his sleep apnea. The private physician elaborated that research shows that psychiatric disorders are commonly associated with sleep apnea and a recent study found that subjects with depression have a higher prevalence of sleep apnea and that the prescription of C-PAP treatment decreased symptomology of both sleep apnea and depression, providing further evidence of their co-morbidity. Because the private physician provided a thorough rationale supported by a review of the medical records, supporting literature, an interview of the Veteran, and his experience, his positive medical opinion is afforded substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. (Continued on the next page) The above evidence reflects that there is a competent, probative medical opinion that weighs in favor of service connection for the Veteran's sleep apnea secondary to his service-connected PTSD, and no probative evidence against. The preponderance of the evidence is therefore in support of the claim for entitlement to service connection for sleep apnea secondary to service-connected PTSD on a causation basis, and the claim must be granted. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board JR Cummings, 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.