Citation Nr: 22017333 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 17-01 635 DATE: March 24, 2022 ORDER Entitlement to an initial compensable rating prior to December 15, 2016 for pseudofolliculitis barbae (PFB) is denied. Entitlement to an initial rating of 10 percent, and no higher, for the period starting on December 15, 2016 and prior to February 13, 2018, for PFB is granted. Entitlement to a rating of 30 percent, and no higher, for the period starting on February 13, 2018 for PFB is granted. Entitlement to service connection for migraine headaches is granted. FINDINGS OF FACT 1. Prior to December 15, 2016, the Veteran's PFB affected less than 5 percent of the entire body and was not prescribed with systemic therapy. 2. From December 15, 2016 and to February 13, 2018, the Veteran underwent intermittent systemic therapy via doxycycline for a total duration of less than six weeks during a 12-month period. 3. From February 13, 2018, the Veteran underwent systemic therapy via doxycycline for a total duration of six weeks or more, but not constantly, during a 12-month period. 4. The evidence is at least in equipoise as to whether the Veteran's migraine headaches was incurred in his active military service. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating prior to December 15, 2016 for PFB have not been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.118, Diagnostic Code (DC) 7899 (2021). 2. The criteria for entitlement to a 10 percent rating, and no higher, from December 15, 2016 and prior to February 13, 2018 have been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.118, DC (2021). 3. The criteria for entitlement to a 30 percent rating, and no higher, from February 13, 2018 have been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.118, DC 7899 (2021). 4. The criteria for entitlement to service connection for migraine headaches have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 3.307, 3.309, 3.310 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Navy from January 1985 to January 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2012 and April 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In December 2018 and September 2021, the Board remanded the claims on appeal to the Agency of Original Jurisdiction for additional development. A supplemental statement of the case (SSOC) was issued in November 2021. The Veteran's VA claims file was subsequently returned to the Board. Higher Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. During the appeal period, VA published a final rule amending its regulations on skin disabilities effective August 13, 2018. The amendment, in pertinent part, added a General Rating Formula for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824, and amended DCs 7801, 7802, 7817, 7819, 7825, 7826, 7827, 7829. See 83 Fed. Reg. 32, 592 (July 13, 2018). Claims pending prior to the effective date are to be considered under both old and new rating criteria, and whichever criteria is more favorable to the Veteran will be applied. Under the regulations in effect at the time the Veteran filed his claim, DC 7899-7806 provided the following: 60 percent: more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 30 percent: 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. 10 percent: at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. 0 percent: less than 5 percent of the entire body or less than 5 percent of exposed areas affected; and no more than topical therapy required during the past 12-month period. 38 C.F.R. § 4.118, DC 7899-7806. Under the new regulations, effective August 2018, DC 7899-7806 is evaluated under the General Rating Formula for the Skin as follows: 60 percent: at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required during the past 12-month period. 30 percent: at least one of the following: characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. 10 percent: at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA or other immunosuppressive drugs required for a total duration of less than six weeks over the past 12-month period. 0 percent: no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118, DC 7899-7806. The Federal Circuit addressed the meaning of "systemic" and "topical" for rating skin disabilities under the regulatory criteria prior to August 31, 2018. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). For these purposes, systemic therapy means treatment pertaining to or affecting the body as a whole, whereas topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied. Id. at 1355. The Federal Circuit acknowledged that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that is affected the body as a whole, but the Court emphasized that this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. Id. Rather, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the facts of each case. Id. at 1356. Effective August 31, 2018, VA regulations explicitly state that for the purposes of the skin disability ratings, "systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin." 38 C.F.R. § 4.118(a). 1. Entitlement to an initial compensable rating for PFB prior to December 15, 2016. The Veteran contends that he should be considered for a compensable disability rating of 15 to 30 percent for his PFB. See Form 9, VA 646 Statement of Accredited Representative in Appealed Case, Appellate Brief, and September 2020 VA 21-4138 form. Turning to the medical record, in October 2012, the Veteran was afforded a VA examination. There, the Veteran reported that he applied over-the-counter (OTC) cortisone cream every night to his beard region and had bumps scattered throughout that area. The Veteran used cortisone on a "constant/near constant" basis. The VA examiner indicated that the affected area was less than five percent of the body. In January 2014, the Veteran submitted a statement noting that he suffers from shaving bumps that at times becomes infected and painful to the touch. See January 2014 VA 21-4138 form. For the period prior to December 15, 2016, the evidence does not show that the Veteran's PFB was characterized by a compensable rating under either the old or new criteria of DC 7899-7806. As noted above, the only finding as to the Veteran's skin was noted at the October 2012 VA examination, where the affected area was less than five percent of the body. In addition, the only form of medication used for treatment was OTC cortisone, which was later determined to not be a form of systemic therapy that will be explained in greater detail below. While the Board finds the Veteran's statements of painful shaving bumps to be credible, the condition is rated based on a percentage of the area affected or the use of systemic therapy. Accordingly, the Board finds that the Veteran was not eligible for a compensable rating for this period. 2. Entitlement to an initial rating of 10 percent, and no higher, for the period starting on December 15, 2016 and to February 13, 2018 for PFB. At private medical treatment on December 15, 2016, the Veteran reported shave bumps and indicated that this has been going on since he started shaving. He reported the use of cortisone cream provided some relief, but indicated that the "bumps never totally go away". The Veteran's primary care physician, Dr. R.J., prescribed doxycycline to be taken orally daily for four weeks. See October 2020 Medical Treatment Record Non-Government Facility. In January 2017, the Veteran indicated that he is taking doxycycline for treatment. See Form 9. For the period from December 15, 2016 and prior to February 13, 2018, the evidence shows that the Veteran's PFB was characterized as a 10 percent rating under either the old or new criteria of DC 7899-7806. Here, no examinations were conducted in order to determine that the percentage of the affected area of the Veteran's body increased due to PFB. However, the Veteran was prescribed doxycycline for a period of four weeks. The Board notes that doxycycline was later determined to be a form of systemic therapy that will be explained in greater detail below. Accordingly, an initial compensable rating of 10 percent, and no higher, for the Veteran's PFB is warranted from December 15, 2016 and prior to February 13, 2018. 3. Entitlement to a rating of 30 percent, and no higher, for the period starting on February 13, 2018 for PFB. Pursuant to the December 2018 Board remand, the Veteran was afforded a VA examination in September 2019. There, the VA examiner indicated that the Veteran used topical cortisone on a constant/near-constant basis and took doxycycline orally six weeks or more but not on a constant basis. The VA examiner indicated that the affected area was less than five percent of the body. The VA examiner noted that corticosteroids are a class of medications that are related to cortisone, a steroid. She further indicated that systemic therapy is any oral or parenteral medication prescribed by a medical professional to treat the underlying skin disorder and therefore, counter cortisone can be classified as systemic therapy. In June 2020, the September 2019 VA examiner provided an addendum opinion. There the VA examiner noted that tetracycline is noted to be given orally for six weeks or more but not constantly over the last 12 months timeframe at the time of the DBQ and is considered to be systemic therapy. The VA examiner indicated that the Veteran uses cortisone topically, constantly or near constantly, in addition to the oral tetracycline. In September 2020, the Veteran indicated that he has been using doxycycline continuously from February 13, 2018 and noted that his primary care physician, Dr. RJ, prescribed the medication to treat his PFB. See October 2020 VA 21-4138 form. In September 2020, a private treating physician provided a positive nexus opinion. See September 2020 Medical Treatment Record Non-Government Facility. In October 2020, a private treatment medical provider, Dr. D.M., noted that the Veteran has continually been taking doxycycline since February 13, 2018 and can be considered "systemic therapy." Dr. D.M. also opined that the Veteran's PFB affects between 20 to 40 percent of his exposed skin as evidenced by the photos procured at the November 2019 VA examination. Dr. D.M. indicated that the past VA examinations noting that the Veteran's PFB scarring only affects less than five percent of his exposed skin is demonstrably wrong given the pictures documented by the VA. Pursuant to a September 2021 Board remand, the Veteran was afforded another VA examination in November 2021. There, the Veteran reported that he took doxycycline a couple of times a month and used OTC hydrocortisone cream. The VA examiner found that the Veteran's use of OTC hydrocortisone is not absorbed by the skin to such an extent that it has systemic effects. For support, the VA examiner cited to studies that noted the dosages were not potent enough to produce a systemic effect as potent medications. In particular, the VA examiner noted that: (1) potent medications are not sold OTC, they are prescribed; (2) hydrocortisone cream is the weakest/mildest class of steroids, class VII and there are seven classes; (3) he was not prescribed hydrocortisone and it is not for long-term or daily usage; (4) it is a topical cream for local irritation and possibly inflammation, in this case for PFB. The VA examiner also indicated that unlike oral corticosteroids that affect your entire body instead of just a particular area, this route of administration (as well as IV, IM, inhalation), is the most likely to cause significant side effects. The November 2021 VA examiner disagreed with Dr. D.M.'s finding that the Veteran's PFB impacted 20 to 40 percent of his exposed skin. The VA examiner cited to medical literature that indicated the total body surface area of the front face is 3.5 percent and neck is 1 percent. The VA examiner estimated the bearded portion of the Veteran's face to be approximately a third of the face from the end of ear to the other end of the ear measuring about 1.15 percent and adding the neck to make it 2.15 percent. Furthermore, the VA examiner indicated that the Veteran's hydrocortisone is not an immunosuppressant drug or a systemic drug. The VA examiner elaborated that hydrocortisone is in a class of medications called corticosteroids and it is used as an immunosuppressive drug given by injection in the treatment of severe allergic reactions; however, in the Veteran's case, it is for a mild local irritation. The Board finds that at no point of the Veteran's appeal did he meet the criteria for a compensable rating for his PFB under the basis of the percentage of the affected body under either the old or new criteria of DC 7899-7806. As noted above, various VA examiners noted that the affected area only impacted less than 5 percent of his body. In particular, the Board finds the November 2021 VA examiner's opinion to be the most probative. In determining that the Veteran's total surface area affected was 2.15 percent, the November 2021 VA examiner referenced medical literature and provided a calculation with detailed estimates of how he determined the area affected. The Board has considered Dr. D.M.'s opinion that the Veteran's PFB affects between 20 to 40 percent of his exposed skin but affords little probative value to his opinion. In reaching his conclusion, Dr. D.M. did not provide a rationale as to how he came to this determination aside from his review of the Veteran's photo. In addition, Dr. D.M. provided a rather large estimate of 20 to 40 percent to show the area that the Veteran's PFB affects, whereas the November 2021 VA examiner provided a more precise finding to the hundredths decimal point and provided a detailed rationale in how he came to such a conclusion. Next, as noted above, the Board finds that the Veteran's OTC cortisone cream use does not constitute systemic therapy. The Board considered the September 2019 VA examiner's opinion that cortisone can be classified as systemic therapy. However, the Board finds the November 2021 VA examiner's opinion to be more probative. In finding that the Veteran's use of OTC hydrocortisone was not potent enough to produce a systemic effect, the November 2021 VA examiner indicated that the dosage was not potent enough to produce a systemic effect, potent medications are not sold OTC, hydrocortisone cream is the weakest/mildest class of steroids, the Veteran was not prescribed hydrocortisone and it was not for long-term or daily usage, and it was a topical cream for local irritation and possibly inflammation. In addition, the November 2021 VA examiner referenced various studies as well as an article from Cleveland Clinic to support his finding that hydrocortisone was not an immunosuppressant drug or a systemic drug. Unlike the November 2021 VA examiner, the September 2019 VA examiner's rationale was rather brief and did not cite to any medical literature in support of her opinions. Therefore, the Board finds that at no point of the Veteran's appeal did he meet the criteria for a compensable rating for his PFB on the basis of his OTC cortisone use under either the old or new criteria of DC 7899-7806. Furthermore, the Board affords no probative value to the September 2020 private treating physician's positive nexus opinion, as it opines on an already established fact and was given without any support or rationale. Finally, as noted above, the evidence indicates that the Veteran's use of doxycycline constitutes systemic therapy. The Board finds the September 2019 VA examiner's opinions and Dr. D.M.'s opinions that the Veteran's doxycycline is systemic therapy to be probative. The September 2019 VA examiner noted that the Veteran took doxycycline orally six weeks or more but not constantly. She also noted that systemic therapy is any oral or parenteral medication prescribed by a medical professional to treat the underlying skin disorder. In an addendum opinion, she indicated that tetracycline was given orally for six weeks or more but not constantly over the last 12 months and that it is considered systemic therapy. This was affirmed in October 2020 by Dr. D.M. As there are no other conflicting opinions regarding doxycycline, the Board finds their opinions to be probative. For the period from February 13, 2018 and onward, the evidence shows that the Veteran's PFB more nearly approximates a 30 percent rating pursuant to either the old or new criteria of DC 7899-7806. As noted above, at a VA examination in September 2019, the Veteran's VA examiner noted that the Veteran took doxycycline orally six weeks or more, but not on a constant basis. This was affirmed by Dr. D.M. in October 2020, as it was noted that the Veteran has been using doxycycline continuously since February 13, 2018. Therefore, the Board finds that the Veteran required systemic therapy for a total duration of six weeks or more, but not constantly, during the past 12-month period. Accordingly, a rating of 30 percent, and no higher, for the Veteran's PFB is warranted from February 13, 2018 and onwards. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(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 or aggravated during service" also known as the "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of (caused) or worsened beyond its natural progression (aggravated) by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt is resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran and his wife are competent to describe symptoms observable to their senses but not to diagnose radiculopathy or other disabilities of the musculoskeletal or neurologic systems as this requires specialized medical training. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 1. Entitlement to service connection for migraine headaches. After reviewing the record, the Board finds the criteria for service connection for migraine headaches have been met. 38 C.F.R. § 3.303. First, the evidence shows a current disability. At a VA examination in November 2021, the VA examiner diagnosed the Veteran with migraine including migraine variants. Thus, the first element of service connection is satisfied. See Holton, 557 F.3d at 1366. Next, the evidence shows that the Veteran was involved in a motor vehicle accident, where he struck the windshield of a vehicle with his head and sustained head injuries. While the Veteran's treatment records were silent as to migraine headaches, he has credibly reported issues with migraine headaches after the motor vehicle accident. The Board finds no reason to doubt the Veteran's reports of migraine headaches in service. Thus, the evidence shows an in-service accident and onset of headaches, which satisfies the second element of service connection. See Holton, 557 F.3d at 1366. Finally, the Board finds the evidence is at least in equipoise that the Veteran's current migraine headaches are related to his service. The Veteran has consistently reported the onset of migraine headaches after the motor vehicle accident during service and continuous migraine headaches throughout the years. See Form 9, VA 646 Statement of Accredited Representative in Appealed Case, September 2020 VA 21-4138, and Appellate Brief. In August 2013, the Veteran was afforded a VA examination. There, the Veteran reported that his migraines started after the July 2000 motor vehicle accident. He indicated that he never experienced headaches until days after the accident. The Veteran reported headaches for three to four months with pain that last up to two hours for four to five times per month. He reported using OTC medication for treatment. A nexus opinion was not provided. In September 2019, the Veteran was afforded a VA examination. There, the Veteran indicated that his headaches began subsequent to his car accident while stationed in Italy. He reported pulsating or throbbing head pain as well as pain that was localized in the right side of his head. He indicated that he experiences head pain once every month for less than one day, nausea, sensitivity to light, and sensitivity to sound. The VA examiner opined that it was less likely than not that the Veteran's migraine headaches had its onset during service. For support, the VA examiner noted that the Veteran was involved in a motor vehicle accident and was seen but had no evidence of injury. The VA examiner noted that the etiology could not be determined, as the Veteran refused Traumatic Brain Injury screening. In August 2020, the Veteran was afforded a VA examination. There, the VA examiner opined that it was less likely that the Veteran's claimed migraine headaches had its onset during active-duty service, manifested within one year following separation from service, or originated during active service to include the result of a motor vehicle accident during service. In support, the VA examiner noted that after the Veteran's motor vehicle accident, his service treatment records were silent as to headaches and shortly after leaving service in June 2005, he only had evidence of hypertension. The VA examiner noted that there was no documentation of migraine headaches while on active duty or shortly thereafter until October 2009. The VA examiner also noted that possible etiologies of the Veteran's migraine headaches included blood pressure, stress, alcohol, and caffeine use. In September 2020, the Veteran's private treating physician provided a positive nexus opinion, but did not provide a rationale in support of her opinion. In October 2020, a private treatment medical provider, Dr. D.M., opined that the Veteran's migraine headache was at least as likely as not a result of the head injury he sustained during service in the United States Navy. Dr. D.M. noted that the Veteran experienced trauma to the head from a motor vehicle accident that resulted in a broken windshield and lodged shards of glass into his scalp. He indicated that it is not unreasonable to assume that the Veteran's brain suffered injury from such an impact and although it is difficult to ascertain the extent of an injury as a traumatic brain injury examination is not present, there is a strong correlation between brain injury and residual migraine headaches. Moreover, Dr. D.M. noted that the Veteran and his wife reported headaches that are consistent with residual complications of a head injury. Dr. D.M. expressed his disagreements with the November 2019 opinion, as Dr. D.M. found the VA examiner's rationale to be very weak. He noted that it relied on the absence of records of traumatic brain injury and ignored the well-documented head trauma the Veteran experienced. He also indicated that while it is not medical certitude, it is certainly at least as likely as not that the accident is the cause of his headaches. Dr. D.M. also expressed his disagreements with the August 2020 opinion, as he noted that the VA examiner misapplied the "at least as likely as not" standard by stating other possible causes of migraine headaches such as elevated blood pressure. He noted that while there are studies that link migraines to hypertension, there is no consensus that a nexus exists and that there are studies that indicate hypertension must be severe and that blood pressure must rise quickly and that headaches caused by extremely elevated blood pressure are not defined as migraine headaches and are a medical emergency. In November 2021, the Veteran was afforded a VA examination. There, the VA examiner opined that it was less likely than not that any migraine headache disability had its onset during active service. The VA examiner acknowledged that the Veteran was involved in a motor vehicle accident, struck his head on the windshield, and sustained several injuries. However, the VA examiner noted that there was no evidence of headaches or signs of symptoms of head pain in the records until six years after a motor vehicle accident. The VA examiner cited to the lack of reports of headaches or migraine symptoms in his service treatment records as well as records that indicated denial of any headaches until 2009. The VA examiner also opined that it was less likely than not that the Veteran's sleep apnea aggravates his migraine headaches. The VA examiner further noted that research studies done as of date failed to find a causal relationship between obstructive sleep apnea and migraine. The Board finds the VA examiners' opinion to be less probative, as they relied on the absence of documentation and did not adequately consider the Veteran's credible lay statements of continuous migraine headache symptoms. See Nieves-Rodriguez, 22 Vet. App. at 295. In addition, the Board affords little probative value to the September 2020 private treating physician's positive nexus opinion, as it was conclusory and did not provide a rationale in support of her opinion. Alternatively, the Board finds Dr. D.M.'s opinions to be probative. Dr. D.M. adequately considered the Veteran's lay statements as to ongoing symptoms with migraine headaches that stemmed from the Veteran's motor vehicle accident. Moreover, Dr. D.M. considered the lack of a traumatic brain injury examination but also took into account of the severe impact that the Veteran had with the vehicle's windshield, the various injuries sustained on his head, and found that his wife and the Veteran's reported migraine headaches are consistent with residual complications of a head injury. Dr. D.M.'s opinion, along with the Veteran and his wife's lay reports of continued migraine headaches, weighs in favor of nexus to service. Given that the Veteran has a current diagnosis of a migraine, his competent reports as to the onset and continuity of his migraine symptoms, and the opinions being in relative equipoise as to whether the Veteran's current migraine is related to his service, reasonable doubt will be resolved in favor of the Veteran. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2021). Based on the foregoing, the Board finds that the evidence satisfies all three elements of service connection for migraine headaches. See Holton, 557 F.3d at 1366. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Kim, 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.