Citation Nr: 22018097 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 17-36 017A DATE: March 28, 2022 REMANDED Entitlement to an initial compensable rating for sinusitis, maxillary, frontal, is remanded. Entitlement to an initial compensable rating for migraine headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1972 to January 1976. These matters are before the Board of Veterans' Appeals (Board) on appeal from September 2016 and November 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In his July 2017 VA Form 9 Substantive Appeal, the Veteran requested a hearing before the Board. The Veteran withdrew his request in March 2022. Entitlement to an initial compensable rating for (1) sinusitis, maxillary, frontal, and (2) migraine headaches are remanded. The Veteran is appealing the initial rating of 0 percent for sinusitis, maxillary, frontal, effective December 29, 2015, and the initial rating of 0 percent for migraine headaches, effective April 10, 2014. The most recent VA examinations were completed in August 2016 (for sinusitis) and in November 2016 (for migraine headaches). The Veteran's September 2021 brief called for new examinations to assess the severity of his symptoms. Statements from the Veteran and prison treatment records indicate that the Veteran has reported incapacitating headaches at various times in recent years. See, e.g., NOD, March 20, 2017 ("I suffer chronic migraines at least twice a month that cause me to be bedridden due to photo/phonic attacks"); Correspondence, January 15, 2019 (stating that a recent headache "was one of the worst to date. It lasted over 19 hours and I really felt ill"); Medical Treatment Record - Non-Government Facility, September 20, 2019, p142 (stating that the Veteran reported two recent migraine headaches "which were severe and interfered with daily functioning.") The Veteran's November 2016 Notice of Disagreement reported sinusitis several times per year, and his September 2021 brief stated that these symptoms have continued and requested a new examination. As this evidence indicates a worsening of his symptoms since the examinations completed in 2016 and the medical evidence contains reports of medical visits which might support the Veteran's position, the Veteran should be afforded a new VA examination to assess the current severity of his sinusitis and migraine headaches. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); 38 C.F.R. § 3.327; VAOPGCPREC 11-95 (1995). The Veteran has also contended that the medications he takes for his migraine headaches have incapacitating side effects, and that his use of the medications masks the severity of his symptoms. See document labeled Hearing Related, received March 1, 2022, 6 pages. The Board requires a medical opinion to address these contentions. The Veteran is currently incarcerated and therefore the RO must arrange an examination in accordance with VA procedures for the examination of incarcerated veterans. The matters are REMANDED for the following actions: 1. Schedule the Veteran for two examinations by an appropriate clinician to determine the current severity of his service-connected (1) sinusitis and (2) migraine headaches. i. The examinations should be scheduled according to the appropriate guidance for scheduling examinations for incarcerated veterans. Notice of any scheduled examination should also be provided to the Veteran's representative at her current address. ii. If the Agency of Original Jurisdiction (AOJ) is unable to afford the Veteran an examination due to incarceration, document in detail all of the steps taken in attempting to do so. If the AOJ is able to afford the Veteran an examination, then the claims file must be made available to the examiner in conjunction with the examination. 2. For the examination concerning the Veteran's sinusitis, the examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner's attention is directed to the Veteran's statement in his November 2016 Notice of Disagreement that he has sinusitis several times per year. 3(a). For the examination for the Veteran's migraines, the examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The clinician should evaluate the Veteran's disability without consideration of the ameliorative effects of the Veteran's medication. The examiner's attention is directed to: i. The Veteran's statement that he suffers chronic headaches at least twice a month which cause him to be bedridden (See NOD, March 20, 2017); ii. His statement that a recent headache lasted over 19 hours and that the Veteran felt ill (See Correspondence, January 15, 2019); iii. The prison treatment records including reports of two headaches in August and September 2019 "which were severe and interfered with daily functioning," (See Medical Treatment Record - Non-Government Facility, September 20, 2019, p142); and iv. The Veteran's statement that his migraine headaches are so severe that he must go to bed, place a towel over his eyes, put earplugs in his ears and remain there. (See VA 21-4138 Statement In Support of Claim, January 25, 2021). 3(b). Finally, the examiner must consider and address the Veteran's contention that his headache medications has incapacitating side effects. See document labeled Hearing Related, received March 1, 2022, 6 pages. Specifically, the clinician should answer the following question: i. What functional side-effects does the Veteran claim from his medication for his service-connected migraine condition? ii. Does the Veteran's medication for his migraine (a) cause or (b) aggravate the identified functional impairment beyond its natural progression? Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected condition. Ian M. Hitchcock Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Dean, 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.