Citation Nr: 21040218 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 17-18 627 DATE: July 2, 2021 ORDER Service connection for headaches is granted. FINDING OF FACT 1. The Veteran has a current diagnosis of headache syndrome. 2. The Veteran fell off a truck and sustained a head injury during service. 3. Symptoms of headaches began during service and have been present since service separation. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for headaches have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran, who is the Appellant, served on active duty from May 1971 to May 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision from the Regional Office (RO), which, in pertinent part, denied service connection for migraine headaches. In April 2020, the Veteran testified at a Board virtual hearing before the undersigned Veterans Law Judge. The hearing transcript has been associated with the record. This case was previously before the Board in March 2021, where the issue on appeal was remanded to obtain a VA examination and medical opinion from a VA examiner. While cognizant of its responsibilities under Stegall v. West, 11 Vet. App. 268 (1998), as the Board grants service connection for headaches, which is a total grant of benefits as to the issue on appeal, the Board need not address Remand compliance at this time. Service Connection for Headaches is Granted. The Veteran contends that service connection for headaches is warranted due to a head injury sustained when he fell off the back of a truck during service. The Veteran testified that at the time of the fall he hit his head and sustained an injury above the left eye. The Veteran asserts that he had headaches after the accident that have continued since then. He describes the headaches as starting on the left side of his head and radiate to the other side and back of the head. The Veteran testified that he was prescribed Imitrex for headaches years ago, but he stopped taking the medication because if was ineffective. See April 2020 Board Hearing Transcript. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. Initially, the Board finds that the Veteran currently has headaches. See June 2005, December 2006 VA treatment records; March 2021 VA examination report. The service treatment records show that the Veteran sustained a head injury in June 1982 during service when he fell off the back of a truck and sustained a gash wound on the left forehead. See June 1982 service treatment record. The Board finds the Veteran's account of in-service head injury to be credible and consistent with the places, types, and circumstances of his service. 38 U.S.C. § 1154(a). After a review of all the lay and medical evidence of record, the Board finds that the evidence is at least in equipoise on the question of whether symptoms of severe head pain, in service and since service separation, that were later diagnosed as headache syndrome, are related to the in-service head injury, i.e., whether current headaches were directly "incurred in" service. As noted above, a June 1982 service treatment note shows that the Veteran was seen and treated for a laceration on the left forehead after falling off the back of a truck. He reported problems with headaches after the head trauma. Subsequent service notes indicate additional reports of headaches when reading and when wearing glasses in 1989 and 1992. See June 1982, April 1989, September 1992, February 1993 service treatment records. A July 1993 VA examination reports indicates that the Veteran reported falling off a truck in 1981 during service. The Veteran reported that he used his hand to protect his head, but he sustained an injury above his left brow when he landed, and that he has had occasional headaches since the in-service fall. See July 1993 VA examination report. Post-service treatment records reflect diagnosis of headache syndrome, which was treated with various medications including Midrin, Fiorinal, Imitrex and Gabapentin between 1997 and 2006. See June 1997, October 2000, January 2002, January 2005, June 2005, December 2006 VA treatment records. The Veteran has provided credible lay statements and testimony that he has continued to have occasional headaches since service, which can last 15 to 45 minutes in duration. See April 2020 Board Hearing Transcript, March 2021 VA examination report. The Veteran was provided a VA examination and medical opinion in March 2021. The VA examiner opined that it is less than likely that the current headache syndrome is related to service, including the 1982 head injury during service. The VA examiner noted that there were no complaints of headaches during the service separation examination or on previous medical history forms during service. The examiner noted that there were complaints of headaches that appeared to be related to his reading glasses prescription, but there is no indication of continued headaches once the prescription was changed. The VA examiner also noted that during a July 1993 VA examination the Veteran did report occasional headaches since falling off the truck in service. Notwithstanding this history, the VA examiner inaccurately indicated that there is no indication that the Veteran's current headaches are related to the head injury during service, as the headaches began in approximately 1998, 17 years after the Veteran fell off the truck during service. See March 2021 VA examination report. The Board gives the March 2021 VA opinion no probative weight as it is not based on an accurate factual history. Specifically, the VA examiner did not consider the June 1982 service treatment note that shows that the Veteran complained of headaches after he fell off the truck; rather, the examiner inaccurately assumed there were no headaches until 17 years later. Additionally, while the examiner asserts that additional reports headaches appeared to resolve once the Veteran's prescription glasses were changed, this factual assumption is also inconsistent with the other evidence of record. The record shows reports of headaches related to reading and the Veteran's prescription glasses in 1989 and 1992; however, during the July 1993 VA examination, the Veteran reported the he continued to have occasional headaches since the in-service fall during. This reported history tends to show that the headaches did not resolve with adjustment of the prescription for the reading glasses in 1992. See June 1982, April 1989, September 1992 service treatment records, July 1993 VA examination report. Moreover, the July 1993 VA examination reports shows that headaches were present within one year of service separation and post-service records shows treatment for headaches within five years of service separation. The Veteran has provided credible lay reports of headaches related to falling off a truck in 1982, during the 1993 VA examination, and during the Board hearing. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis, but cannot reject the opinion solely because the history was from the veteran). As the weight of the evidence shows headaches beginning in service and off and on since service, the VA examiner's factual assumptions that headaches did not start until 17 years after the head injury is an inaccurate assumption that renders the purported opinion of no probative value. While the Veteran's headaches are not a chronic disease listed under 38 C.F.R. § 3.309(a), as indicated above, the Board has nonetheless found the evidence at least in equipoise on the question of whether the Veteran had symptoms of head pain that began during service and continued since service separation, which symptoms were later diagnosed as headaches, thus tending to show direct service incurrence. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). The Board is granting the service connection claim based on evidence, including that pertinent to service, which establishes that symptoms of headaches disability began in service, so was "incurred in" service. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for direct service connection for headaches have been met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, Shanna 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.