Citation Nr: 22017586 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 18-21 841 DATE: March 25, 2022 REMANDED Entitlement to service connection for migraine headaches, to include as due to herbicide agent exposure and as secondary to service-connected tinnitus, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1966 to August 1968. This case comes before the Board of Veterans' Appeals (Board) on appeal from January 2018 and March 2018 rating decisions issued by the Department of Veterans Affairs (VA). In September 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is associated with the claims file. The Board remanded the case for further development in September 2020. The case has since been returned to the Board for appellate review. Upon review, the Board finds that additional development is needed prior to adjudication of the issue on appeal. A November 2020 VA examiner opined that the Veteran's headaches were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. She noted that his service treatment records were negative for any complaints, diagnosis, or treatment and that the Veteran was first documented as having migraine headaches in October 2014. The examiner acknowledged that the Veteran's report continuity of symptomatology since service, but she commented that a layperson is not qualified to ascribe symptoms to a diagnosis or to determine the etiology. She stated that there a gap of 46 years, and therefore, an intercurrent injury or disease cannot be ruled out as the etiology. She noted that a MRI had revealed that the Veteran has cavernomas, which are congenital and could be the cause of his headaches. In addition, the examiner observed that a January 2019 VA treatment record had documented that his headaches began 10 to 15 years earlier with no preceding events and were diagnosed as a chronic migraine variant with possible triggers being untreated obstructive sleep apnea and cervical spondylosis. She concluded that there is no medical evidence to support a finding that the Veteran's migraine headaches are directly due to his military service or began during service. The examiner further stated that the medical literature does not support Agent Orange or noise exposure as a cause of migraine headaches. The November 2020 VA examiner also opined that the Veteran's migraine headaches were less likely than not proximately due to or the result of the Veteran's service-connected tinnitus. She indicated that migraine headaches and tinnitus are not medically related, as migraine headaches are an entirely separate entity, and the medical literature does not demonstrate a causal relationship. The examiner also commented that migraine headaches are not fully understood, but that genetics and environmental factors appear to play a role and that changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway, might be involved, as could be imbalances in brain chemicals, including serotonin, which helps regulate pain in the nervous system. In a January 2021 addendum, the same VA examiner opined that the Veteran's migraine headaches are less likely than not aggravated beyond their natural progression by his service-connected tinnitus. She indicated that she was unable to determine the Veteran's baseline condition; however, she stated that there is insufficient objective evidence in the Veteran's medical records to establish permanent aggravation or aggravation by increased manifestations of the Veteran's migraine headaches by the service-connected tinnitus. Nevertheless, the Board notes that a February 2018 VA examiner had previously stated that there is evidence of a vascular abnormality in this case (i.e., cavernomas) that were found on an August 2015 brain MRI and brain angiogram. The brain MRI had also revealed hemosiderin on the right medial occipital lobe and noted that hemosiderin is seen with bleeds. The examiner also indicated that cavernomas bleed at times and present as headaches. She concluded that it is more likely than not that the Veteran's headaches are related to his right and left cavernomas, which are congenital or sporadic. Although the November 2020 VA examiner later found that the cavernomas were congenital, she did not explain that finding, to include why they are considered congenital rather than sporadic. Nor did she indicate whether they were a congenital defect or disease, which is significant in that service connection can be granted if a congenital defect was subjected to a superimposed disease or injury during service which created additional disability, such as migraine headaches. Therefore, the Board finds that an additional medical opinion is needed. The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for migraine headaches not already of record. See September 2020 hearing transcript (Veteran testified he has been seeing doctors for his headaches about 25 years). After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should request a VA medical opinion to determine the etiology of the Veteran's migraine headaches. A physical examination is only needed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, the September 2020 hearing transcript, and lay statements. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether the evidence is at least an approximate balance that the Veteran has headaches that manifested during service or that are otherwise causally or etiologically related to his military service, to include any noise exposure, symptomatology, and presumed herbicide exposure therein (notwithstanding the fact that such an association is not presumed). In so doing, the examiner should consider the Veteran's medical history, including vascular abnormalities, such as the diagnosis of cavernomas and any resulting bleeding, in addressing whether his headaches may have manifested during service or whether a vascular or brain disorder started during service, which is the cause of his current headaches. If the examiner finds that the Veteran's cavernomas are a congenital defect or disease, he or she should provide an explanation for that finding. For any congenital defect, he or she address whether the defect was subjected to a superimposed disease or injury during service which created the additional disability of migraine headaches. The examiner should also opine as to whether the evidence is in at least approximately balanced to find that any current migraine headaches are either caused by or aggravated by his service-connected tinnitus. In rendering his or her opinion, the examiner should address both the causation and aggravation questions. In other words, even if the Veteran's service-connected tinnitus did not cause his current headaches, the examiner should still address whether the service-connected tinnitus aggravates his headaches. The examiner should also note that the aggravation prong of secondary service connection requires a worsening of the claimed disorder, but not a permanent worsening of the claimed disorder. The law provides that compensation is due for any incremental increase in disability, meaning any additional impairment of earning capacity above the degree of disability existing before the increase, in a nonservice-connected disability resulting from a service-connected disability, regardless of its permanence. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The AOJ should ensure compliance with the foregoing directives and conduct any other development as needed. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Kuczynski, 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.