Citation Nr: 22011125 Decision Date: 02/25/22 Archive Date: 02/25/22 DOCKET NO. 17-13 256 DATE: February 25, 2022 ORDER Entitlement to service connection for migraine headaches, including due to exposure to environmental hazards in the Persian Gulf, is denied. REMANDED Entitlement to service connection for vision problems, to include as secondary to migraine headaches, is remanded. Entitlement to service connection for dizziness, to include as secondary to migraine headaches, is remanded. FINDING OF FACT The evidence of record persuasively weighs against finding that migraine headaches began during active service, are otherwise related to an in-service injury or disease, are related to environmental exposures in the Persian Gulf, or are due to or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for migraine headaches are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1987 to June 1987 and December 1990 to May 1991. The Veteran had service in Southwest Asia during the Persian Gulf War. The above issues were most recently before the Board in August 2021 when they were remanded for additional development. The Board finds there has been substantial compliance with the remand directives for the claim decided herein. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for migraine headaches, including due to exposure to environmental hazards in the Persian Gulf. The Veteran contends that his migraine headache disability is related to his active service, including exposure to environmental hazards in the Persian Gulf. 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. In order to obtain a grant of service connection pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, a Veteran needs to present some evidence (1) that he or she is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (a); see Neumann v. West, 14 Vet. App. 12, 22 (2000), vacated on other grounds, 14 Vet. App. 304 (2001) (per curiam order); Gutierrez v. Principi, 19 Vet. App. 1 (2004). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117; 38 C.F.R. § 3.117, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. Medically unexplained chronic multisymptom illnesses are defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases). Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2). In this case, the Veteran's military personnel records show that he has served in the Southwest Asia theater of operations, so he is considered a Persian Gulf veteran for the purposes of applying VA regulations under 38 C.F.R. § 3.117. In February 2015 the Veteran reported that he had headaches that were typically prompted by being in crowds and around people. Upon examination in February 2015 the Veteran was noted to not have any diagnosed, medically unexplained chronic multisymptom illnesses. Specifically, the Veteran did not have fibromyalgia, irritable bowel syndrome, or chronic fatigue syndrome. The Veteran was afforded a VA headache examination in April 2015. The Veteran was diagnosed with migraine headaches. The examiner found that it was less likely as not that the Veteran's migraine headaches were proximately due to or the result of his PTSD. However, the examiner did not provide any rationale for the opinion. In a VA medical opinion dated in August 2015 it was noted that although much about the cause of migraine headaches is not understood, genetics and environmental factors appear to play a role. Migraine headaches may be caused by changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway. Imbalances in brain chemicals, including serotonin which helps regulate pain in your nervous system, also may be involved. Serotonin levels drop during migraine attacks. This may cause the trigeminal system to release substances called neuropeptides which travel to the brain's meninges and the result is headache pain. The examiner noted that whatever the exact mechanism of the headaches, a number of things may trigger them. Common migraine headache triggers included hormonal changes in women, foods, food additives, alcohol, stress, sensory stimuli, changes in wake-sleep pattern, physical factors, changes in the environment, and medications. The Veteran was first noted to have post-traumatic stress disorder on the mental health compensation and pension examination dated in February 2015. Prior to that the Veteran was not being followed by psychiatry and was not taking any psychiatric medications. The Veteran began having headaches as early as 2003 and was not formally diagnosed with migraine headaches until approximately 2012 which is long before ever being labelled with post-traumatic stress disorder. Therefore, the examiner opined that the Veteran's migraine headaches are less likely as not proximately due to or the result of his post-traumatic stress disorder. In September 2017 a fellow Veteran reported that the Veteran had headaches whenever they would drive through areas with explosions, burning pits, heavy smoke and oil residue. A private provider reported in October 2017 that the Veteran's migraines are triggered by exposure to fire pits, loud explosions or noises, and explosives. In February 2019 a private provider reported that the Veteran had headaches treated by another provider. It was noted that the Veteran had significant exposure to chemical hazards including smoke and oil residue. In a December 2019 VA headache examination the Veteran was diagnosed with migraine headaches. A December 2019 VA Gulf War examination reported that the Veteran had headaches 3 to 4 times weekly. The Veteran was afforded a VA traumatic brain injury (TBI) examination in January 2020. The Veteran had a history of being diagnosed with PTSD associated with depression, nervousness, stress and impaired sleep. The Veteran began having temporal parietal headaches in 2003 associated with nausea, vomiting and visual changes two to three times per week. Veteran was evaluated for headaches in April 2015, and it was determined that he had a diagnosis of migraine headaches. It was reported that the examiner opined that migraine headaches were less likely than not a residual of the Veteran's PTSD. A VA medical opinion was obtained in January 2021. The examiner found that the claimed condition is less likely than not proximately due to or the result of Veteran's service-connected condition. The examiner found that the conditions of migraine and PTSD are not medically related. The migraine is a separate entity entirely from the PTSD and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship. The examiner continued to state that though migraine causes are not fully understood, genetics and environmental factors appear to play a role. Changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway, might be involved. The examiner stated that imbalances in brain chemicals may also be involved. In another January 2021 VA medical opinion it was found that the Veteran's headaches were not aggravated by his PTSD. The examiner stated that medical evidence does not support the Veteran's migraine headaches as being aggravated by his PTSD. The examiner again reported that there are a number of migraine triggers. A VA medical opinion in October 2021 reported that the Veteran's headaches were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. There were insufficient medical records to indicate that Veteran's migraines began during service. The examiner reported that the Veteran's service years were 1990 to 1991 and no records indicating complaints of migraines could be found during that time. It was found that the Veteran's migraine diagnosis was not made until 2016, approximately 24 years after discharge from service. The examiner reported that the etiology and pathophysiology of the Veteran's migraine headaches was partially understood. The Veteran reports that he had headaches beginning during deployment to Southwest Asia in 1991 but there were insufficient medical records to provide objective evidence that would help determine the etiology of his headaches. The Veteran reported that the headaches worsened years after discharge from service and the examiner found that this makes another etiology more likely, rather than something that occurred during service. When diagnosed with migraines in 2016, it was noted that he had uncontrolled hypertension and a hypertension examination report completed in April 2015 indicated he had an average blood pressure of 151/103. The examiner reported that it is well known that headaches, and/or migraines are triggered by uncontrolled hypertension. The examiner reported that a hard copy of an examination report completed by his neurologist in 2016 was provided by the Veteran. That form indicated that the Veteran was diagnosed with migraines, along with having blood pressure problems. Therefore, the examiner found that it appeared that the Veteran's migraines were mostly understood to be due to blood pressure problems. The examiner found that they were not at least as likely as not incurred in or otherwise related to active service. There is insufficient objective evidence to determine whether the headache condition began during service. The examiner stated that it is most likely that his headache/migraine condition developed as his uncontrolled hypertension developed, which was several years after service. In another October 2021 VA medical opinion the Veteran's disability was reported to be a diagnosable chronic multi-symptom illness with a partially explained etiology. The examiner found that it was not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The Veteran's migraines were noted by his neurologist in 2016 to have occurred along with blood pressure problems and repeated the findings of his blood pressure in 2015. The examiner reiterated that it was well known that uncontrolled hypertension may cause symptoms of headaches as well as migraines. The examiner concluded that since this corresponds to the time when Veteran was diagnosed with migraines and had occurred about 24 years since service in Southwest Asia, the hypertension is more likely the cause of his migraines rather and a specific exposure event in Southwest Asia. Entitlement to service connection for migraine headaches is not warranted. Although the Veteran served in the Southwest Asia theater of operations, the Veteran has not been found to have an undiagnosed illness or a medically unexplained chronic multi-symptom illness. In addition, migraine disability is not a disability for which the Secretary has determined warrants a presumption of service connection. Additionally, examiners have found that the Veteran's disability was not related directly to service, to include any exposure to environmental hazards in Southwest Asia. VA examination has found that although the Veteran is in receipt of service-connected benefits for PTSD, the Veteran's migraine disability is not due to or aggravated by his PTSD disability. Rather, probative opinions of record indicate that the Veteran's disability is associated with the Veteran's nonservice-connected hypertension disability. In light of the foregoing, the Board finds that the evidence is persuasively against the claim, and the benefit of the doubt doctrine is not for application. The appeal must therefore be denied. REASONS FOR REMAND 1. Entitlement to service connection for vision problems, to include as secondary to migraine headaches, is remanded. 2. Entitlement to service connection for dizziness, to include as secondary to migraine headaches, is remanded. The Veteran seeks entitlement to service connection for vision problems and has contended that they are related to his PTSD. He has also contended that his vision problems are related to his service in the Persian Gulf and migraine headaches. VA medical opinions were obtained in December 2019, March 2020, September 2020, October 2020, and October 2021. Notably, a VA medical opinion in October 2021 the examiner noted that the Veteran's symptoms of dizziness, nausea, vomiting, sensitivity to light and sound all occurred with headaches and were solely due to migraine headaches. However, adequate opinions regarding whether the Veteran's vision disability and dizziness were aggravated by the Veteran's service-connected PTSD disability has not been obtained. Rather, examiners have found that the Veteran's disabilities were not aggravated beyond natural progression by PTSD. Therefore, the claims must be remanded for adequate medical opinions. See 38 C.F.R. § 3.159. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician regarding the likely etiology of the Veteran's vision and dizziness disabilities. Copies of all pertinent records must be made available to the examiner for review. Following review of the record, the clinician should address the following: Is it as least as likely as not the Veteran's vision and/or dizziness disabilities are (i) caused or (ii) aggravated by the Veteran's service-connected disabilities, specifically posttraumatic stress disorder? Aggravation here is defined as any increase in disability. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner's own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made. 2. Confirm that the VA medical opinions provided comport with this remand, specifically that the standard for the secondary aggravation opinions is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. B. G. LeMoine Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert J. Burriesci, 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.