MIGRAINE

Summary

The veteran, who served from April 1979 to April 1983, appeals the denial of service connection for migraine headaches, both directly and as secondary to his service-connected tinnitus. The Board considered the evidence of record, including the veteran's testimony and multiple VA medical opinions. The veteran has a current diagnosis of migraine headaches and is service-connected for tinnitus. While service treatment records noted headaches in the temporal area associated with sinus pressure during service, there was no specific diagnosis or documentation of migraines during service. A VA examiner in October 2023 provided a negative nexus opinion, stating migraines are genetically influenced and not linked to TERA or Camp Lejeune exposure, and that the veteran's STRs did not indicate migraine symptoms. This opinion was found adequate. A subsequent VA addendum opinion in January 2024 also provided a negative nexus, noting migraines are linked to elevated blood pressure and stress, and that the veteran's STRs did not indicate migraine symptoms, only headaches related to sinusitis. This opinion also found migraines do not typically cause tinnitus, though tinnitus can be a symptom of migraines. The Board afforded significant probative weight to these opinions. The veteran testified that tinnitus worsens his migraines and loud noise triggers them, but the Board found the evidence weighed against service connection on any theory, noting the benefit-of-the-doubt doctrine was inapplicable as the evidence preponderated against the claim. Service connection for migraine headaches was denied.

Rationale

No in-service diagnosis of migraines; VA opinions found no nexus to service or tinnitus; Migraines have genetic component and are linked to hypertension/stress

Full Decision Text

Citation Nr: 24012054
Decision Date: 03/14/24	Archive Date: 03/14/24

DOCKET NO. 18-52 724
DATE: March 14, 2024

ORDER

Entitlement to service connection for migraine headaches, to include as secondary to service-connected tinnitus, is denied.

FINDING OF FACT

The Veteran's migraine headaches first manifested many years after service and have not otherwise been found to be related to his service; nor are they caused or aggravated by service-connected disabilities.

CONCLUSION OF LAW

The criteria for entitlement to service connection for migraine headaches, to include as secondary to service-connected tinnitus, has not been met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from April 1979 to April 1983.  This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision from a Department of Veteran Affairs (VA) Regional Office (RO).

The Veteran testified at a hearing before the undersigned Veterans Law Judge in August 2023.  A transcript of the hearing has been associated with the claims file.

As a preliminary matter, in September 2023 and December 2023, the Board remanded the matter for further medical development.  It now returns to the Board for further consideration.

With regard to the sufficiency of the VA medical opinions on the issue, the Board finds there was substantial compliance with the prior remand directive. Stegall v. West, 11 Vet. App. 268, 271 (1998).  Forcier v. Nicholson, 19 Vet. App. 414, 425 (2006).

Entitlement to service connection for migraine headaches, to include as secondary to service-connected tinnitus. 

The Veteran contends his migraine headaches are due to his military service, to include as secondary to his service-connected tinnitus.  

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303.  Generally, service connection requires three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury.  Sheddon v. Principi, 381 F.3d. 1163, 1166-67 (Fed. Cir. 2004).

Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(a).  Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability.  Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).  Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability.38C.F.R. §310(b).

In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant.  38 U.S.C. § 5107; 38 C.F.R. § 3.102.

Turning to the medical evidence of record, the Veteran has a current diagnosis of migraine headaches and is service-connected for tinnitus.  See VBMS, document labeled CAPRI, receipt date 9/5/2018, page 144 of 151.  As such, the first element required for service connection has been met.

At the August 2023 Board hearing, the Veteran testified to not remembering having migraine headache problems while in service.  According to his service treatment records (STRs), there is documentation of headaches around his temporal area associated with sinus pressure.  See VBMS, document labeled STR-Medical, receipt date 12/8/2015, page 28 of 126.  However, aside from that single notation, there is no additional medical evidence of migraine headaches during the Veteran's military service.  Regardless, the Board finds the second element required for service connection has been met.

Furthermore,
9/5/2018, page 144 of 151.  As such, the first element required for service connection has been met.

At the August 2023 Board hearing, the Veteran testified to not remembering having migraine headache problems while in service.  According to his service treatment records (STRs), there is documentation of headaches around his temporal area associated with sinus pressure.  See VBMS, document labeled STR-Medical, receipt date 12/8/2015, page 28 of 126.  However, aside from that single notation, there is no additional medical evidence of migraine headaches during the Veteran's military service.  Regardless, the Board finds the second element required for service connection has been met.

Furthermore, there is a VA memo in the Veteran's claims file that he participated in toxic exposure risk activity (TERA).  Specifically, the memo stated the Veteran had non-deployment related exposure as he had potential exposure to explosive substances and combustion byproducts due to his military occupation specialty (MOS) of a rifleman.  See VBMS, document labeled Other, receipt date 9/21/2023. Notably, the Veteran was not noted to be qualified for any other toxic exposure based on his military service, to include contaminated water at Camp Lejeune. 

Therefore, the remaining question is whether there is a nexus, i.e., whether the Veteran has a current disability that at least as likely as not began during service or is at least as likely as not related to an in-service injury, disease, or event; or whether it is caused or aggravated by his service-connected tinnitus.  

In October 2023, a VA medical opinion was obtained to determine whether there is a medical nexus between the Veteran's TERA and his migraine headaches.  The examiner noted that the Veteran's caregiver thought he had Camp Lejeune exposures and then proceeded to provide a negative nexus medical opinion and explained that migraines are a genetically influenced complex disorder characterized by episodes of moderate to severe headache, most often unilateral and generally associated with nausea and increased sensitivity to light and sound; that migraines have a strong genetic component, and; that the risk of migraines in ill relatives is three times greater than that of relatives of non-ill subjects, but no inheritance pattern was identified.  The examiner cited that there is no nexus to Camp Lejeune toxic water ingestion and migraines, in the literature, to support a nexus.  As such, the examiner opined the Veteran's migraine headaches is less likely as not caused by TERA.  As the examiner reviewed the Veteran's military medical treatment records, post-military medical treatment records, and reconciled their rationale with substantiated reasoning with supported medical facts from the Veteran's claims file, the Board affords this opinion probative weight.  Furthermore, the Board notes that migraine headaches are not considered a chronic disease subject to presumptive service connection per 38 C.F.R. § 3.309.

Following the December 2023 Board remand, in January 2024, a VA medical addendum opinion was obtained to determine the nature and etiology of the Veteran's migraine headaches.  The examiner provided a negative medical nexus opinion.  The examiner explained there is clear evidence in the Veteran's file that his migraine headaches are related to elevated blood pressure, possibly secondary to job-related and other stressors.  The examiner added that elevated blood pressure and stress are known triggers for migraine headaches and there is no evidence of migraine headaches or other recurrent headaches during service.  The examiner referred to the Veteran's STR on April 28, 1981 in which he reported headaches in the temporal region during an episode of acute sinusitis, and explained that a headache in the temporal area is common with sinus pressure and tension headaches, but is not typical of migraine headaches.  The examiner further added that reviewed medical literature shows that migraines are typically one-sided, occur with throbbing or pulsating pain and will come with nausea and/or vomiting and light and/or sound sensitivity, which are hallmark symptoms for diagnosing a migraine headache.  Given the aforementioned, the examiner explained the Veteran's STR does not indicate symptoms of a migraine headache and there is no evidence in the Veteran's file that the headache due to the sinusitis persisted or recurred during service.  As the examiner reviewed the Veteran's military medical records, post-military medical treatment records, and peer-reviewed medical literature reconciled with confirmed medical facts, the Board affords this opinion significant probative weight.  

At the August 2023 Board hearing, the Veteran also testified that his service-connected tinnitus makes his migraine headaches worse and that loud noise triggers his migraine headaches.  See VBMS, document labeled Hearing Transcript, receipt date 8/1/2023, page 5 of 8.

Following the September 2023 Board Decision, in October 2023, a VA medical opinion was obtained regarding
 and there is no evidence in the Veteran's file that the headache due to the sinusitis persisted or recurred during service.  As the examiner reviewed the Veteran's military medical records, post-military medical treatment records, and peer-reviewed medical literature reconciled with confirmed medical facts, the Board affords this opinion significant probative weight.  

At the August 2023 Board hearing, the Veteran also testified that his service-connected tinnitus makes his migraine headaches worse and that loud noise triggers his migraine headaches.  See VBMS, document labeled Hearing Transcript, receipt date 8/1/2023, page 5 of 8.

Following the September 2023 Board Decision, in October 2023, a VA medical opinion was obtained regarding the nature and etiology of the Veteran's migraine headaches.  In December 2023, the Board found the October 2023 VA medical opinion was inadequate, per El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of "not due to," not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 3.310(b)), because the examiner provided a medical opinion as to causation, but not aggravation.  As such, in December 2023, the Board remanded the matter for an addendum medical opinion.    

In January 2024, another VA medical addendum opinion was also obtained to address whether the Veteran's migraine headaches are secondary to his service-connected tinnitus.  The examiner also provided a negative medical nexus opinion that the Veteran's migraine headaches are less likely than not caused or aggravated by his service-connected tinnitus.  The examiner reiterated the Veteran's migraines are related to elevated blood pressure and possibly secondary to job-related and other stressors and that elevated blood pressure and stress are known triggers for migraine headaches.  However, the examiner explained there is also clear evidence that migraines did not exist during service, but have worsened over time due to the Veteran's hypertension and that there is no evidence in previous exam notes to support a connection between the Veteran's tinnitus and migraine headaches.  The examiner supported their rationale with a review of medical literature that shows that migraine headaches can cause tinnitus, but there is no evidence to support the reverse relationship that tinnitus causes or aggravates migraine headaches.  As the examiner reviewed the Veteran's military medical records, post-military medical treatment records, and peer-reviewed medical literature reconciled with confirmed medical facts, the Board affords this opinion significant probative weight.

In summary, the Board finds that the persuasive evidence weighs against entitlement to service connection on any theory of entitlement. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the persuasiveness of the evidence is against the claim, the doctrine is not applicable. 38 C.F.R. § 3.102 (2015), Gilbert v. Derwinski, 1 Vet. App. 39, 54-56 (1990). The evidence is not in relative equipoise for service connection for migraine headaches under any reasonably raised theory, to include secondary service connection. There is no reasonable doubt to resolve in the Veteran's favor, and the appeal is denied.

 

Bethany L. Buck

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	R. Smith, 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.