Citation Nr: A25110313 Decision Date: 12/23/25 Archive Date: 12/23/25 DOCKET NO. 250325-531578 DATE: December 23, 2025 ORDER Service connection for residuals of a traumatic brain injury (TBI) is granted. Service connection for post-traumatic migraines, secondary to service-connected residuals of a TBI on a causation basis, is granted. Service connection for peripheral vestibular disorder, secondary to service-connected residuals of a TBI on a causation basis, is granted. FINDINGS OF FACT 1. While serving in the United States Navy Reserves, the Veteran served a period of active service from June 13, 2002, to June 27, 2002. 2. With the resolution of all reasonable doubt in the Veteran's favor, during his period of active service from June 13, 2002, to June 27, 2002, the Veteran sustained a TBI as a result of which he continues to experience residual symptoms. 3. With the resolution of all reasonable doubt in the Veteran's favor, the competent evidence of record establishes that his current diagnosis of post-traumatic migraines is one of the symptoms of his now service-connected residuals of a TBI. 4. With the resolution of all reasonable doubt in the Veteran's favor, the competent evidence of record establishes that his current diagnosis of peripheral vestibular disorder (claimed as dizziness) is one of the symptoms of his now service-connected residuals of a TBI. CONCLUSIONS OF LAW 1. The criteria for the entitlement to service connection for residuals of a TBI have been met. 38 U.S.C. §§ 101(24), 1110, 5107; 38 C.F.R. §§ 3.6(c)-(d), 3.102, 3.303, 3.304. 2. The criteria for the entitlement to service connection for post-traumatic migraine, secondary to service-connected residuals of a TBI on a causation basis, have been met. 38 U.S.C. §§ 101(24), 1110, 5107; 38 C.F.R. §§ 3.6(c)-(d), 3.102, 3.10. 3. The criteria for the entitlement to service connection for peripheral vestibular disorder, secondary to service-connected residuals of a TBI on a causation basis, have been met. 38 U.S.C. §§ 101(24), 1110, 5107; 38 C.F.R. §§ 3.6(c)-(d), 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Navy Reserves from March 2002 to October 2009, which included a period of service for training from June 13, 2002, to June 27, 2002. These matters come before the Board of Veterans' Appeals (Board) on appeal of a January 2025 rating decision issued by a Department of Veterans Affairs (VA) regional office, an agency of original jurisdiction (AOJ). In a March 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran timely initiated an appeal of the January 2025 rating decision and elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time the AOJ issued the January 2025 rating decision on appeal, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from, the Board's receipt of the March 2025 VA Form 10182. 38 C.F.R. § 20.303. In his March 2025 VA Form 10182, the Veteran also included the issue of entitlement to service connection for hypertension and cited to a July 31, 2024, decision. The decision cited is a July 2024 Board decision; therefore, the Board has construed it as a motion for reconsideration, which will be addressed by the Board in separate ruing on the motion. Service Connection A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active military, naval, air, or space service. 38 U.S.C. §§ 1110, 1131. Under 38 U.S.C. § 101(2), a "veteran" is defined as "a person who served in the active military, naval, air, or space service, and who was discharged or released therefrom under conditions other than dishonorable." The term "active military, naval, air, or space service" includes: (1) active duty; (2) any period of active duty for training (ADT) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and; (3) any period of inactive duty for training (IDT) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101(21), (22), (24); 38 C.F.R. § 3.6 (a)-(d); Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). In order to establish veteran status with respect to a period of ADT and, therefore, eligibility for service connection, the record must establish that the servicemember was disabled or died due to a disease or injury incurred or aggravated in the line of duty during that period. See Paulson v. Brown, 7 Vet. App. 466, 470 (1995). In order to establish veteran status with respect to a period of IDT and, therefore, eligibility for service connection, the record must establish that the servicemember was disabled or died from an injury incurred or aggravated in the line of duty during that period. Id. In the absence of such evidence, the period of ADT or IDT would not qualify as "active military, naval, air, or space service," and the servicemember would not qualify as a "veteran" for that period of ADT or IDT service alone. As relevant to this appeal, in the case of a member of the Reserves, ADT is full-time duty in the Armed Forces for training purposes, to include authorized travel to and from such duty. 38 U.S.C. § 101(22)(A), (E). Also, as relevant to this appeal, IDT is duty (other than full-time duty) prescribed for Reserves by the Secretary concerned under 37 U.S.C. § 206 or any other provision of law as well as additional special duties authorized for the Reserves by an authority designated by the Secretary concerned and performed by them on a voluntary basis in connection with the prescribed training or maintenance activities of the units to which they are assigned, and training (other than for ADT). 38 U.S.C. § 101(23)(A), (B). Generally, in order to establish service connection, there must be competent and credible evidence demonstrating (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability that is caused or aggravated by a service-connected disease or injury. 38 U.S.C. § 1110; 38 C.F.R. § 3.310(a), (b). In Spicer v. McDonough, the United States Court of Appeals for Veterans Claims (Court), clarified the standard of proof for claims based on a secondary service connection theory of entitlement. 61 F.4th 1360, 1364-65 (Fed. Cir. 2023). In accordance with the Court's holding in Spicer, secondary causation exists when the service-connected disability is the but-for cause of the nonservice-connected disability, which is not limited to a single cause and effect, but rather contemplates multi-causal links. Id. Secondary aggravation may exist when the nonservice-connected disability would be less severe were it not for a service-connected disability, to include where the natural progression not caused by the service-connected disability would have nonetheless been less severe were it not for the service-connected disability. Id. at 1364. Ordinarily, a lay person is competent to report symptoms and experiences observable by their senses; however, usually, they are not competent to prove a matter requiring medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 470 (1994). The issue of entitlement to service connection for residuals of a TBI. The issue of entitlement to service connection for migraines. The issue of entitlement to service connection for peripheral vestibular disorder. The Veteran seeks service connection for a head injury, migraines, and peripheral vestibular disorder (which he also claimed as dizziness). See November 2017 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits; March 2021 VA Form 20-0995, Decision Review Request: Supplemental Claim; March 2025 VA Form 10182. The Veteran asserts that since the time of his head injury in service in 2002, he has experienced the symptoms of dizziness, headaches, nausea, and blurred vision three to four times weekly with a severity that causes him to slur his speech and stagger from dizziness. See March 2021 VA Form 21-4138, Statement in Support of Claim. He stated that he has experienced these symptoms continuously from the day of the injury to the present. He denied having experienced any of these symptoms prior to the injury in service. He also reports that since his head injury he has additionally experienced confusion, memory loss, vertigo, and tinnitus. See December 2020 VA Ear Conditions Examination Report. Prior to this appeal, the Veteran was not service connected for any disability; therefore, veteran status for any period of his Reserves service had not been established. For the reasons discussed below, the Board finds that veteran status has been established from June 13, 2002, to June 27, 2002, and service connection for the disabilities claimed here are warranted based on that period of service. Preliminarily, the Board notes that the AOJ has confirmed the Veteran had active service while serving in the United State Navy Reserves from June 13, 2002, to June 27, 2002. See September 2018 Information Report (labeled as Certificate of Release or Discharge from Active Duty). Additionally, the AOJ in the January 2025 rating decision favorably found that a qualifying event, injury, or disease occurred during the Veterans service; specifically, his service treatment records (STRs) show a head injury with complaint of headaches that incurred in the line of duty on June 17, 2002. 38 C.F.R. § 3.104(c). No clear or unmistakable error has been shown to rebut this favorable finding. Id. Therefore, the Board is bound by this favorable finding. As such, the in-service incurrence element of service connection has been met. In fact, the Veteran's STRs from June 17, 2002, noted that he hit his head on a window and thereafter complained of dizziness, lightheadedness, headache, nausea, and blurred vision. However, the STRs indicated there was no loss of consciousness. At that time, the treatment provider noted an assessment of "post-headache without a concussion and concluded he was found fit for duty. With respect to the service connection claim for peripheral vestibular disorder, the AOJ also favorably found that the Veteran had a current diagnosis of peripheral vestibular disorder based on a December 2020 VA examination. 38 C.F.R. § 3.104(c). No clear or unmistakable error has been shown to rebut this favorable finding. Id. Therefore, the Board is bound by this favorable finding. As such, the current disability element for the claim for service connection for peripheral vestibular disorder has been met. Considering the above, the Board must first address whether the current disability element for the claims of service connection for residuals of a TBI and migraines may be met. In that regard, there is conflicting evidence of record. With respect to the claim for service connection for Following a November 2020 VA initial evaluation of residuals of a TBI, the examiner concluded that the Veteran did not have any residuals of a TBI despite the Veteran's report of continued symptoms since his injury in service, to include impaired speech, confusion, memory loss, migraines, and dizziness. Whereas, in a March 2021 VA medical opinion, the examiner acknowledged that the Veteran had sustained a mild TBI in service upon review of the relevant STRs. Thereafter, in an August 2024 VA medical opinion, another examiner concluded that the Veteran did not have any residuals of a TBI because his initial injury in service did not meet the criteria for either a mild concussion or mild TBI. In doing so, the examiner discussed the common symptoms of post-concussion syndrome, which included headaches, memory changes, concentration difficulty, imbalance, dizziness, and nausea were among the common. The examiner concluded he did not meet the criteria for a diagnosis because his STRs did not support the finding that his initial injury was substantial enough to account for any of his current symptoms. Moreover, the examiner stated symptoms of post-concussion syndrome are present at the time of a concussion and loss of consciousness or presents and do not improve after 10 days of initial injury. The examiner concluded that the Veteran's symptoms did not manifest until years later, which is inconsistent with a mild head injury. Subsequently, in their March 2025 private medical opinion, Dr. R.P. concluded that the Veteran sustained a TBI in service and presently experiences residuals thereof. In light of the above and the Veteran's competent lay report of continued symptoms since his injury in service, the Board resolves all reasonable doubt in his favor and finds that he has a current diagnosis of residuals of a TBI. 38 U.S.C § 5107(b); 38 C.F.R. § 3.102. With respect to the claim for service connection for migraines, following a November 2020 VA headaches examination, the examiner concluded the Veteran did not have any diagnosis of a disability manifested by headaches despite the Veteran's report of continued migraines three to four times per week since his injury in service. Whereas, in a March 2025 private medical opinion from Dr. R.P., a Doctor of Osteopathic Medicine. Dr. R.P. diagnosed the Veteran with post-traumatic migraines following a review of his claims file, to include his STRs. In view of the foregoing and the Veteran's competent lay report of headaches since his injury in service, the Board resolves all reasonable doubt in his favor and finds that he has a current diagnosis of post-traumatic migraines. 38 U.S.C § 5107(b); 38 C.F.R. § 3.102. As a current diagnosis for each of the claims disabilities has been met and an in-service injury has been conceded, the only element remaining for each of the claims is whether there is a nexus between the current diagnoses and the in-service injury. Consistent with the Board's findings in its July 2024 decision, that VA medical opinions obtained in November 2020, December 2020, January 2021, and March 2021 are inadequate for adjudication purposes, the Board will focus on the nexus opinions received after March 2021. In the August 2024 VA medical opinion, the examiner proffered a negative nexus opinion as to all three claims. In doing so, the examiner concluded that the Veteran's current symptoms were not related to his service as he did not sustain a mild concussion or mild TBI in service. Further, they were not related to his "minor head injury" in service given the "paucity of evidence to suggest any temporal relationship." Based on the Board's findings herein that, with the resolution of all reasonable doubt in the Veteran's favor, the Veteran did sustain TBI in service as a result of which he experiences residual symptoms presently, the August 2024 VA medical opinion is inadequate for adjudication purposes because it is inconsistent therewith. Consequently, the only remaining nexus opinion is Dr. R.P.'s March 2025 private medical opinion. In authoring their opinion, as noted above, Dr. R.P. indicated having review the claims file, to include the Veteran's STRs. Additionally, Dr. R.P. cited a various medical literature in support. Dr. R.P. opined that the Veteran's current condition was at least as likely as not due to the head injury the Veteran sustained in service. Dr. R.P. stated that it was clear that the Veteran sustained a significant head injury in June 2002, when he slipped during a training exercise and stuck his head on a thick glass wall, which resulted in a loss of consciousness, blurred vision, slurred speech, and the immediate onset of migraines. Dr. R.P. took issue with prior VA examiners' findings as they failed to account for the Veteran's persistently reported and medically consistent symptoms. Dr. R.P. explained that even mild TBIs can lead to long-terms neurocognitive dysfunction, especially, when unrecognized and untreated. According to Dr. R.P., the Veteran demonstrated a continuous pattern of TBI-related symptoms, to include migraines and vestibular disturbances, since the time of his injury. Further, Dr. R.P. indicated that medical literature supports a finding that even mild TBIs, particularly those involving impact and brief altered consciousness, can result in chronic migraine development. Thus, his migraines were at least as likely as not secondary to his head injury in service. Likewise, his peripheral vestibular disorder was at least as likely as not secondary to his head injury in service. In that regard, Dr. R.P. explained that following mild head injuries, the peripheral vestibular system may suffer significant impairment, which can compromise vestibular function. Referencing various medical literature in support, Dr. R.P. concluded that the Veteran's symptom profile aligned with the known pathophysiological outcomes of head trauma. "The anatomical vulnerability of the vestibular labyrinths - housed within the temporal bone - renders them particularly susceptible during blunt force trauma." The Board acknowledges Dr. R.P.'s opinion is not entirely medically consistent with the Veteran's STRs which indicated there was no loss of consciousness at the time of injury. However, regardless of whether he lost consciousness in service, Dr. R.P.'s opinion states that these symptoms may result from even a mild head trauma. Given the Veteran's STRs clearly document a head injury in service, the Board affords Dr. R.P.'s March 2025 medical opinion probative weight. Moreover, Dr. R.P.'s March 2025 medical opinion is the most probative nexus opinion of record. Considering the above, with the resolution of all reasonable doubt in the Veteran's favor, the Board finds that the evidence of record demonstrates that he sustained a TBI in-service during his period of Reserve training from June 13, 2002, to June 27, 2002, which constitutes active service. 38 U.S.C § 5107(b); 38 C.F.R. § 3.102. As a result of that TBI in-service, he now experiences post-traumatic migraines and peripheral vestibular disorder. (Continued on the next page) ? Accordingly, service connection is granted for the residuals of a TBI; post-traumatic migraines, secondary to service-connected residuals of a TBI on a causation basis; and peripheral vestibular disorder, secondary to service-connected residuals of a TBI on a causation basis, is granted. G.J. Suh Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Wright, K. 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.