Citation Nr: 22052688 Decision Date: 09/15/22 Archive Date: 09/15/22 DOCKET NO. 16-53 797A DATE: September 15, 2022 ORDER Entitlement to service connection for a headache disorder is granted. REMANDED Entitlement to service connection for an eye disorder is remanded. FINDING OF FACT The Veteran's headache disorder was incurred in, or caused by, his active duty service. CONCLUSION OF LAW The criteria for entitlement to service connection for a headache disorder have been met. 38 U.S.C. § §§ 1101, 1110, 1131; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1967 to October 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2014 decision by the Department of Veterans Affairs (VA) Regional Office (RO). In April 2022, the Veteran testified at a video-conference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the claims file. 1. Entitlement to service connection for a headache disorder The Veteran asserts that his headache disorder is related to his active duty service. For the following reasons and bases, the Board finds that the criteria for entitlement to service connection on a direct basis have been met. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent medical or lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran has been diagnosed with a headache disorder, specifically psychogenic cephalgia. See February 2014 Headaches Disability Benefits Questionnaire (DBQ). Accordingly, he has a current disability. See Davidson, 581 F.3d 1313. Throughout the appeals period, the Veteran has stated and testified that he first began to experience headaches during his active duty service, which have continued to the present. See August 2013 Statement in Support of Claim; May 2021 Statement in Support of Claim; April 2022 Hearing Transcript. In support of the claim, the Veteran submitted a statement by his sister, which corroborated that he first began experiencing headaches during his active duty service. See Undated K.L.A. Statement, received by VA on May 9, 2016. The Board notes that the Veteran and his sister are competent to report on his in-service headache issues. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (finding that a veteran is competent to report on factual matters of which he has firsthand knowledge); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board also finds these statements credible. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Baldwin v. Brown, 13 Vet. App. 1 (1999) (reflecting that determinations concerning the credibility of evidence are within the purview of the Board). A February 2014 VA examination report provided a positive nexus opinion, finding that the Veteran's current headache disorder was related to his in-service headaches. The examiner's rationale was based on the Veteran's report of continuity. See February 2014 Headaches DBQ. The Board acknowledges that there is a negative etiological opinion of record in the form of a December 2014 VA medical opinion. The opinion found that it is less likely than not that the Veteran's headache disorder is related to his active duty service. The Board finds this opinion inadequate, as it primarily relies on the absence of evidence in the Veteran's post-service medical records. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate when the examiner did not comment on the Veteran's report of in-service injury and instead relied on the absence of evidence in the Veteran's service medical records to provide a negative opinion). In sum, the Board finds that it is as least as likely as not that the Veteran's headache disorder was incurred during active service. In this regard, the Board finds the statements of the Veteran as well as the opinion of the February 2014 VA examiner to be competent, credible, and highly probative of the fact that the Veteran's headache symptomatology began during his active service and has continued since. See Jandreau, 492 F.3d 1372. Although there are conflicting medical records, the Board finds that, at the least, the evidence for and against the claims is in relative equipoise. When the evidence for and against a claim is in relative equipoise, by law, the Board must resolve all reasonable doubt in favor of the Veteran. See 38 U.S.C. § 1154(b); 5107; 38 C.F.R. § 3.102. Therefore, the benefit of the doubt must be resolved in favor of the Veteran and entitlement to service connection for a headache disorder is warranted. REASONS FOR REMAND 1. Entitlement to service connection for an eye disorder is remanded. The Veteran asserts that his eye disorder is secondary to an aneurysm he suffered during his active duty service. See April 2022 Hearing Transcript. His claim was denied, in pertinent part, as the RO did not find evidence of an in-service event, disease, or injury to the Veteran's eye. The Board notes that the Veteran's claim of entitlement to service connection for residuals of an aneurysm was denied in a May 2013 rating decision. However, the Veteran has stated and testified that he first began experiencing eye symptomatology during his active duty service, which has continued to the present. Id.; August 2013 Statement in Support of Claim; May 2016 Correspondence. Furthermore, the Veteran's sister submitted a statement corroborating the onset of the Veteran's eye symptomatology. See Undated K.L.A. Statement, received by VA on May 9, 2016. Additionally, the Board notes that the Veteran is now service-connected for a headache disorder. The Veteran testified that his headache and eye disorders began at the same time during his active duty service, which reasonably raises the possibility that his eye disorder may be secondary to his headache disorder. Given the evidence suggesting that the Veteran's eye disorder may have had its initial onset during service or may be related to his now service-connected headache disorder, the Board finds a remand is required to develop the claim, to include obtaining a VA examination and opinion. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Finally, as this matter is being remanded, the Veteran's updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Make arrangements to obtain the Veteran's VA treatment records, from April 2016, forward. 2. Thereafter, schedule the Veteran for an appropriate VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature and etiology of his eye disorder(s). The entire claims file, to include a copy of this REMAND must be made available to the examiner in conjunction with the opinion. The examiner must confirm in the examination report that he or she has reviewed the folder in conjunction with the examination. The examiner should elicit a fill history from the Veteran. After reviewing the file, eliciting a full medical history from the Veteran, conducting an examination of the Veteran, performing any clinically indicated diagnostic testing, the examiner must provide answers to the following: (a) Identify, by diagnosis, all eye disorders currently attributable to the Veteran (b) For each condition identified, opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's eye condition(s) had its clinical onset during service or is related to any incident of service. * In providing the requested opinion, the examiner must consider and address the statements of the Veteran and his sister regarding the onset and continuity of his in-service symptomatology. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? (c) For each condition identified, provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disorder a was either (i) caused by, or (ii) aggravated (i.e., worsened) by the Veteran's service-connected headache disorder. The examiner must provide a complete rationale for all opinions provided. If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why such opinion could not be rendered. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. M. Stedman, 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.