MIGRAINE

Summary

The veteran, who served in the U.S. Army from November 1963 to August 1966, appeals the denial of service connection for headaches and erectile dysfunction (ED). The veteran contended that his headaches began after an in-service head injury in Vietnam and also claimed they were secondary to his service-connected PTSD and sleep apnea. For ED, the veteran claimed it was secondary to his service-connected PTSD. The VA examination for headaches found the medical record largely silent on complaints or diagnosis, and the examiner did not provide a nexus opinion. However, a private medical report from Dr. J.F., an internal medicine and neurology specialist, found a strong correlation between the veteran's headaches and his service-connected PTSD and sleep apnea, concluding it was more likely than not that these conditions caused his headaches. The Board found Dr. F.'s opinion more probative due to its detailed rationale and the examiner's expertise, concluding the evidence was in approximate balance and granting service connection for headaches on a secondary basis. For ED, the VA examiner opined it was most likely due to age and less likely than not related to service-connected disabilities, but provided no rationale. Dr. F. disagreed, noting age was not a direct cause and that PTSD, neuropathy, sleep apnea, and lumbar spine conditions were strongly associated with ED. He concluded the veteran's ED was more likely than not caused by a combination of these service-connected conditions. The Board found the VA opinion of limited value due to lack of rationale and favored Dr. F.'s detailed opinion, concluding the evidence was in approximate balance and granting service connection for ED on a secondary basis.

Rationale

Private medical opinion found headaches more likely than not caused by PTSD and sleep apnea.; VA examination was largely silent on complaints and provided no nexus opinion.; Evidence found in approximate balance.

Full Decision Text

Citation Nr: A22016689
Decision Date: 08/23/22	Archive Date: 08/23/22

DOCKET NO. 220401-232153
DATE: August 23, 2022

ORDER

Service connection for headaches is granted.

Service connection for erectile dysfunction (ED) is granted.

FINDINGS OF FACT

1. The evidence is in approximate balance as to whether the Veteran's headaches are proximately caused by service-connected disabilities. 

2. The evidence is in approximate balance as to whether the Veteran's ED is proximately caused by service-connected disabilities. 

CONCLUSIONS OF LAW

1. The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for ED have been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Introduction

The Veteran served on active duty in the United States Army from November 1963 to August 1966.

This matter comes before the Board of Veterans' Appeals (Board) on appeal of April 2021 and August 2021 rating decisions issued by the U.S. Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ).

In the April 2022 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the AOJ decisions on appeal, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303.

General Legal Criteria

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d).

In addition, service connection may be established on a secondary basis by establishing that (1) a current disability exists and (2) the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310).

VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

"[I]f the positive and negative evidence is in approximate balance the claimant receives the benefit of the doubt." Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

Analysis

Service connection for headaches

The Veteran has contended that he has headaches that began during service. Specifically, he has contended he suffered a head injury in 1965 when he jumped from a truck that was under attack in Vietnam, and has had headaches ever since. Alternatively, he has contended his headaches are secondary to his service-connected disabilities, to include posttraumatic stress disorder (PTSD).

The Veteran was afforded a VA headaches examination in June 2019. He reported a history of headaches in his mother, and said his headaches began after an in-service injury. He reported one to two headaches per week lasting five minutes at a time. The examiner ultimately noted that the medical record was largely silent for complaints or diagnosis of a headache condition. He further noted he could not locate records of the Veteran's claimed in-service vehicle accident. The examiner did not directly address the Veteran's contentions and did not provide an opinion regarding the probability that the Veteran's headaches were related to
 and has had headaches ever since. Alternatively, he has contended his headaches are secondary to his service-connected disabilities, to include posttraumatic stress disorder (PTSD).

The Veteran was afforded a VA headaches examination in June 2019. He reported a history of headaches in his mother, and said his headaches began after an in-service injury. He reported one to two headaches per week lasting five minutes at a time. The examiner ultimately noted that the medical record was largely silent for complaints or diagnosis of a headache condition. He further noted he could not locate records of the Veteran's claimed in-service vehicle accident. The examiner did not directly address the Veteran's contentions and did not provide an opinion regarding the probability that the Veteran's headaches were related to service or any service-connected disability.

In March 2022, a private medical report was completed by J.F., MD, a specialist in internal medicine and neurology. The report was submitted in April 2022 with the Veteran's VA Form 10182. Initially, Dr. F. noted he had thoroughly reviewed the Veteran's claims file, including all VA examination reports and outpatient records. He then asserted that his analysis would be based on such review and his experience and training in internal medicine, rheumatology, psychiatry, and neurology.

Dr. F. first provided a detailed summary of the Veteran's medical records, noting complaints of headaches intermittently throughout the period of the claim. He noted that no cause for the headaches had been determined by any medical professional. In particular, Dr. F. noted a July 2015 report by the Veteran of headaches when arising from sleep. In this regard, Dr. F. proceeded to discuss the Veteran's service-connected sleep apnea. Dr. F. discussed studies showing significant correlation between sleep apnea and headaches. He explained the specific mechanism of causation as thought to be carbon dioxide retention that occurs during apnea episodes. He noted that this cause would explain the moderate intensity and relatively short duration of the Veteran's headaches. Dr. F. then discussed tension headaches, which, he noted, studies showed often resulted from PTSD. Specifically, Dr. F. explained that PTSD-induced anxiety resulted in increased force of muscle contraction and resultant pain in the scalp and neck muscles, leading to headaches. Ultimately, in the absence of alternative causes identified for the Veteran's headaches, Dr. F. concluded that based on his analysis, it was more likely than not that the Veteran's headaches were both tension headaches and sleep apnea-induced headaches, caused by the Veteran's service-connected PTSD and sleep apnea, respectively.

Upon review of the foregoing, the Board notes that while the VA examination report stated the record was "largely" absent of headaches complaints, the examiner did not address the intermittently documented complaints of headaches, nor the Veteran's own lay statements attesting to frequent headaches. Ultimately, the examiner did not provide a substantive opinion as to the etiology of the Veteran's headaches.

On the other hand, in the March 2022 report, Dr. F. provided a full medical explanation for his opinion that was based on a detailed and accurate review of the Veteran's claims file, and relevant medical literature. The Board also finds that Dr. F.'s background as a physician with expertise in neurology and psychiatry, among other fields, lends additional probative weight to his report.

After careful consideration, the Board finds that the evidence is in at least approximate balance as to whether the Veteran's headaches are proximately due to his service-connected PTSD and sleep apnea. Accordingly, granting of service connection for headaches is warranted.

Because the Board has granted service connection on a secondary basis, it need not address additional bases for service connection raised by the Veteran.

Service connection for ED

The Veteran has contended he has ED secondary to his service-connected PTSD.

The Veteran was afforded a VA male reproductive examination in August 2021. The examiner noted the Veteran's report that his ED had an onset in 2006, which the Veteran noticed coincided with the presence of PTSD symptoms. The examiner initially noted that the rate of ED in patients with PTSD is approximately 85 percent. However, the examiner concluded, the Veteran's ED was most likely due to age and less likely than not a result of the Veteran's service-connected disabilities. The examiner provided no further discussion or explanation of his opinion.

In the March 2022 report discussed above, Dr. F. acknowledged the August 2021 opinion, but observed that no rationale was provided by the examiner. He then explained that while age is an accepted cause of certain physical impairments, this is limited to conditions with known or established causation by the aging process. He then stated that according to the International Classification of Diseases (ICD), a globally-used diagnostic tool, such conditions did not include ED or headaches. As such, Dr. F. stated, ED and headaches could not be considered as attributable to age unless there
 was most likely due to age and less likely than not a result of the Veteran's service-connected disabilities. The examiner provided no further discussion or explanation of his opinion.

In the March 2022 report discussed above, Dr. F. acknowledged the August 2021 opinion, but observed that no rationale was provided by the examiner. He then explained that while age is an accepted cause of certain physical impairments, this is limited to conditions with known or established causation by the aging process. He then stated that according to the International Classification of Diseases (ICD), a globally-used diagnostic tool, such conditions did not include ED or headaches. As such, Dr. F. stated, ED and headaches could not be considered as attributable to age unless there was some additional underlying diagnosis causing the conditions that could be said to be a result of aging. Dr. F. then noted that several of the Veteran's service-connected conditions were shown by medical studies to have a strong statistical association with ED. Specifically, PTSD, neuropathy, lumbar degenerative disease and radiculopathy, and sleep apnea. With respect to PTSD, he noted the VA examiner's citation for the proposition that the rate of ED in patients with PTSD is approximately 85 percent. He further noted that evidence of a causal nexus between PTSD and ED as a psychiatric manifestation was extremely strong and well-defined. Dr. F. explained that causation was thought to be multifaceted, ranging from distraction by thought patterns caused by PTSD, loss of interest in activities, interference with relationships, and a specific mechanism within the spinal neurons that is both a main factor in ED and is impaired by central feedback in severe psychological states.

Dr. F. next noted the severity of the Veteran's lower extremity neuropathy demonstrated by the record, and stated that sensation in the impacted nerves was an important factor for sexual function. As such, he stated that it was as likely as not the Veteran's neuropathy was a major additional causal factor of his ED. Dr. F. then noted that ED was three times more likely in sleep apnea patients, and stated this was due to factors such as sleep disturbances, autonomic nervous system dysfunction, and effects of hypoxia on the spine. Thus, Dr. F. concluded, the Veteran's sleep apnea was an additional causal factor for his ED. Finally, Dr. F. explained that the lumbar spine condition involving nerve root compression that afflicted the Veteran had been demonstrated by studies to have a correlation and causal relationship with ED. He explained that the lower sacral nerve roots are significantly involved in sexual function.

Dr. F. ruled out a previous stroke suffered by the Veteran and the Veteran's hypertension as causes of his ED. Specifically, he explained that the portion of the brain affected by the type of stroke the Veteran had was not associated with sexual function. With respect to hypertension, he explained that the record showed the Veteran's hypertension was too well-controlled to be a factor.

In summary, Dr. F. concluded, the Veteran's ED was of mixed etiology. After review of the record, he concluded the Veteran's ED was more likely than not caused by a combination of his PTSD, neuropathy, sleep apnea, and lower back condition with radiculopathy.

Upon review, as noted by Dr. F., the August 2021 VA examiner provided no rationale or explanation for his opinion. Further, the examiner did not address whether any of the Veteran's service-connected conditions could have aggravated his ED, even if they were not direct causes. For these reasons, the Board finds the VA medical opinion is of limited probative value.

Conversely, the March 2022 report included a detailed and accurate review of the Veteran's medical history, and Dr. F.'s conclusions were clearly explained, while he ruled out other possible causes for ED specific to the Veteran's case. Again, the Board finds that Dr. F.'s background as a physician with expertise in neurology and psychiatry, among other fields, lends additional probative weight to his opinion.

After careful consideration, the Board finds that the evidence is in at least approximate balance as to whether the Veteran's ED is proximately due to a combination of his service-connected PTSD, neuropathy, sleep apnea, and lumbar spine condition. Accordingly, granting of service connection for ED is warranted.

 

 

H. SEESEL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Hampton, 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. 


 combination of his service-connected PTSD, neuropathy, sleep apnea, and lumbar spine condition. Accordingly, granting of service connection for ED is warranted.

 

 

H. SEESEL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Hampton, 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.