Citation Nr: 22017341 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 17-41 320 DATE: March 24, 2022 REMANDED Entitlement to service connection for headaches, to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from August 2009 to November 2009 and from March 2012 to December 2012. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for headaches, to include as secondary to service-connected disabilities, is remanded. In December 2019, the Board remanded the issues of entitlement to service connection for headaches and allergic rhinitis for further development. Specifically, the Board noted that the Veteran's representative contended in a November 2019 appellate brief that her headaches were related to her service-connected irritable bowel syndrome. The Board further noted that the prior November 2015 examiner failed to provide an opinion as to direct service connection. Accordingly, the Board directed the RO to obtain a VA examination and opinion to determine whether the Veteran's headaches are related to either her active service or her service-connected irritable bowel syndrome. After an examination, opinion, and multiple subsequent addendum opinions due to a need for clarification, VA examiners found that it was less likely than not that the Veteran's headaches were related to her active service or her service-connected irritable bowel syndrome. However, the Board notes that the Veteran has contended that her headaches are related to other service-connected conditions and that there are no opinions of record discussing whether her headaches are related to those conditions. The Board specifically notes that the Veteran has contended that her headaches are related to her recently service-connected allergic rhinitis. See Sept. 2021 Rating Decision Narrative. In a January 2015 Statement in Support of Claim, the Veteran characterized her claim for service connection as "headaches/sinus/allergies" and stated that during service, she suffered headaches, sinus, and allergies every day. She contended that the symptoms are related to the environment she experienced during active service, including sand, burn pits, and extreme heat. In a December 2015 post-deployment health note, the Veteran reported that her allergy symptoms "come and go," which caused her to have headaches. See Dec. 2015 CAPRI, pp. 3-4. In a January 2016 post-deployment health note, the Veteran stated that she continued to have headaches, which she attributed to her allergy and sinus symptoms. See May 2017 CAPRI, p. 1. She further stated that she took Claritin and Flonase when she was very congested, but that the episodes had become more frequent and that there was an accompanying headache. Id. In her February 2016 Notice of Disagreement, the Veteran stated that she believed her allergies were the main cause of her headaches. In a July 2016 post-deployment health note, the provider noted a diagnosis of current allergic rhinitis and sinus symptoms with symptoms including recurrent headaches. See May 2017 CAPRI, p. 7. In her July 2017 VA Form 9, the Veteran stated that after her deployment in 2012, she could feel her anger worsening and that she began to have headaches. She also stated that she had frequent headaches from stress, depression, allergies, and her back. In a December 2021 appellate brief, the Veteran's representative provided multiple studies regarding the relation between irritable bowel syndrome and gastroesophageal reflux disease (GERD) and headaches. The representative also provided studies supporting a connection between mood disorders and headaches. The representative further noted that the Veteran's prescription medications for service-connected disabilities may have contributed to or caused her migraine headaches. The Board acknowledges the multiple contentions of record that the Veteran's headaches are related to her sinus and allergy issues and treatment records suggesting a link between the two conditions. In light of the Veteran's recent grant of service connection for allergic rhinitis and the lack of a VA examination opining as to such a connection, the Board finds that remand for a new VA examination and opinion is warranted. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating that the probative value of medical opinion evidence, among other factors, is based on whether a clinician was "informed of the relevant facts" and medical history in rendering a medical opinion). Moreover, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the Jackson Vista electronic records system and are dated March 2021. Any VA treatment records are within VA's constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. The matter is REMANDED for the following action: 1. Ask the Veteran to identify the location and name of any VA or private medical facility where she has received treatment for headaches, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records of her treatment for headaches from any sufficiently identified private treatment provider from whom records have not already been obtained. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's outstanding VA treatment records from the Jackson Vista electronic records system for the period since March 2021; and all such relevant records from any other sufficiently identified VA facility. 3. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for a VA examination to determine the nature of any current headache disability (to include migraines) and to obtain an opinion as to whether such disability is related to service or service-connected disability. Any indicated evaluations, studies, or tests deemed necessary by the examiner should be accomplished. The entire claims file, to include a complete copy of this REMAND, should be made available to the examiner designated to provide an opinion and the examination report should include a discussion of the Veteran's documented medical history and assertions. The examiner must address the following: Determine whether there is an approximately 50 percent chance that any headaches experienced by the Veteran since approximately January 2015 (1) began during any period of active service; (2) manifested within one year after separation from any period of active service; (3) is otherwise related to an injury or disease during service; (4) is caused by service-connected allergic rhinitis, unspecified depressive disorder and unspecified trauma and stressor related disorder, irritable bowel syndrome, gastroesophageal reflux disease, and/or lumbosacral posterior facet arthropathy (to include any medications taken for these disabilities); OR (5) is aggravated by service-connected allergic rhinitis, unspecified depressive disorder and unspecified trauma and stressor related disorder, irritable bowel syndrome, gastroesophageal reflux disease, and/or lumbosacral posterior facet arthropathy (to include any medications taken for these disabilities). *The examiner must address the multiple statements of record in which the Veteran contends that her headaches are related to her sinus or allergy condition. See January 2015 Statement in Support of Claim; February 2016 Notice of Disagreement; July 2017 VA Form 9; December 2021 Appellate Brief. The examiner must also address treatment records supporting such a relationship. See Dec. 2015 CAPRI, pp. 3-4; May 2017 CAPRI, pp. 1, 7. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries and that her reports must be taken into account in formulating the requested opinions. The examiner must provide a rationale for all proffered opinions. Brian J. Elwood Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Watkins, 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.