MIGRAINE

Summary

The veteran, a Marine Corps veteran who served from November 1981 to April 1983, appeals the denial of service connection for migraine headaches. This case has a complex history, having been before the Board of Veterans' Appeals four times prior, with multiple remands to the agency of original jurisdiction (RO) to obtain adequate medical opinions. The veteran has a service-connected disability for PTSD with bruxism at 50%, and also for sinusitis, rhinitis, esophagitis, liver condition, and a right hand fracture, none of which are linked to the migraine claim. The primary issue is whether migraine headaches are related to service, either directly, secondarily, or presumptively. The Board reviewed over fifteen negative medical nexus opinions, with the most recent September 2024 VA examination finding that the veteran's migraines are less likely than not related to service, incurred in service, or proximately due to service-connected conditions. The examiner noted a lack of objective evidence in service treatment records and a lack of continuity of symptoms, finding the veteran's claims of onset in service unsupported by clinical documentation. While acknowledging that migraines can be associated with psychiatric conditions like PTSD, the examiner concluded this was a correlative link, not causal, and that hormonal changes were a stronger potential trigger. The Board found the evidence weighed against service connection, and the benefit of the doubt did not apply as the evidence was not in approximate balance. Service connection for migraine headaches was denied.

Rationale

No objective evidence of in-service onset or continuity of symptoms.; Multiple negative nexus opinions from VA examiners.; Migraines not listed under Camp Lejeune presumptive conditions.; Correlation between PTSD and migraines, but no causal link to service established.

Full Decision Text

Citation Nr: 26004269
Decision Date: 04/07/26	Archive Date: 04/07/26

DOCKET NO. 17-39 889A
DATE: April 7, 2026

ORDER

Entitlement to service connection for migraine headaches is denied.

FINDING OF FACT

The evidence of record persuasively weighs against finding that migraine headaches began during active service or is otherwise related to an in-service injury or disease.

CONCLUSION OF LAW

The criteria for service connection for migraine headaches have not been met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served in the United States the Marine Corps from November 1981 to April 1983. 

This matter comes before the Board of Veterans' Appeals (Board) under the legacy appeal system. 

This matter has previously before the Board four times. First, a March 2019 BVA decision remanded service connection for migraines. The Board directed the RO to schedule an examination for the Veteran's migraines, and to obtain an opinion as to whether it is at least as likely as not that her migraines began during active service or related to an incident of service, including exposure to contaminated water at Camp Lejeune, NC. The matter was remanded three other times by the Board to obtain adequate medical opinions. See December 2021 BVA Decision, January 2023 BVA Decision, and July 2024 BVA Decision. 

More than 15 medical nexus opinions have been obtained by the RO; all have been negative. The most recent medical opinions obtained in September 2024 are discussed in more detail below in this opinion. The September 2024 examiner has reviewed all the past opinions of record and rendered a negative nexus opinion. There are no positive nexus opinions of record. 

The Veteran has been service connected for the primary disability of posttraumatic stress disorder (PTSD) with bruxism with an evaluation of 50 percent effective February 6, 2014. See most recent codesheet. The Veteran has also been service connected for sinusitis, rhinitis, esophagitis, liver condition, right hand 5th and 4th metacarpal fracture, however, none of these conditions relate to migraine headaches. 

Service Connection

Service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus or a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

Service connection may be established on a secondary basis for a disability that is proximately due to, aggravated by, or the result of a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 449 (1995). 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) caused by or (b) aggravated by a service-connected disability. See 38 C.F.R. § 3.310; but see Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (holding all that is needed is a "but for" causation or aggravation to show entitlement to secondary service connection).

Diseases associated with exposure to Contaminants in Camp Lejeune Water Supply are governed under 38 C.F.R. §§ 3.307(a)(7), 3.309(f). If a Veteran was exposed to contaminants in the water supply at Camp Lejeune during service, and one of the below listed diseases manifests to a degree of 10 percent any time after service, that disability is presumed related to the exposure. The list of disabilities under 38 CFR 3.309(f) is: 

(1) Kidney cancer.

(2) Liver cancer.

(3) Non-Hodgkin's lymphoma.

(4) Adult leukemia.

(5) Multiple myeloma.

(6) Parkinson's disease.

(7) Aplastic anemia and other myelodysplastic syndromes.

(8) Bladder cancer. See 38 U
7), 3.309(f). If a Veteran was exposed to contaminants in the water supply at Camp Lejeune during service, and one of the below listed diseases manifests to a degree of 10 percent any time after service, that disability is presumed related to the exposure. The list of disabilities under 38 CFR 3.309(f) is: 

(1) Kidney cancer.

(2) Liver cancer.

(3) Non-Hodgkin's lymphoma.

(4) Adult leukemia.

(5) Multiple myeloma.

(6) Parkinson's disease.

(7) Aplastic anemia and other myelodysplastic syndromes.

(8) Bladder cancer. See 38 U.S.C. 501(a) and 1112(b). 

Although a December 2024 VA memorandum shows exposure to Camp Lejeune Water Contaminants during service, migraine headaches is not listed under 38 CFR 3.309(f) and is not entitled to presumptive service connection due to exposure to Contaminants in Camp Lejeune Water Supply.

1. Entitlement to service connection for migraine headaches is denied.

The Veteran filed an informal claim for 38 conditions including migraines on February 6th, 2014. See February 2014 Informal Claims and more informal claims. Veterans could file informal claims prior to March 24, 2015. From March 24, 2015, a claim must be filed on a designated VA form. See 38 C.F.R. § 3.1(p) (2018); 79 Fed. Reg. 57,696 (Sept. 25, 2014). The Veteran then filed VA 21-526EZ, fully developed claim on June 2nd, 2014, for migraines. 

An October 2015 rating decision denied service connection for migraines because service treatment records (STRs) did not contain complaints, treatment, or diagnosis for migraines. There was no link between the Veteran's medical condition and military service. There was no continuity of symptoms from service to the present.

The Veteran filed a Notice of Disagreement in November 2016. A Statement of the Case was issues in June 2017. A March 2019 BVA decision remanded service connection for migraines. The Board directed the RO to schedule an examination for the Veteran's migraines.

The RO obtained a direct medical opinion regarding migraines in June 2020. See June 2020 medical opinion. The June 2020 examiner found that the Veteran's migraines are not caused by or a result of the Veteran's exposure to contaminated water at camp Lejeune.

The Veteran was provided an in-person Compensation & Pension (C&P) examination in January 2021. See January 2021 C&P Exam. The Veteran was diagnosed with migraine at the examination. 

The Veteran reported that her headaches began in 1982 in service. Since discharge from service in 1983, for a period of approximately 43 years, the Veteran does not have medical evidence supporting continuity of symptomology.  

The matter came before the Board a second time in December 2021. See December 2021 BVA Decision. The Board instructed the RO to obtain opinions regarding various conditions including migraines to determine whether they are (a) at least as likely as not related to service, (b) proximately due to service-connected disability, or (c) aggravated i.e., worsened beyond its natural progression by service- connected disability. 

The RO obtained 4 medical opinions regarding migraines in June 2022: a direct medical opinion, a secondary medical opinion, an aggravation opinion, and an opinion regarding Camp Lejeune exposure. The June 2022 examiner found that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. See June 2022 direct opinion.

The examiner found that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected condition. See June 2022 secondary opinion. The examiner found that the Veteran's migraines were less likely than not aggravated i.e., worsened beyond its natural progression by her service-connected disabilities. See June 20222 aggravation opinion. The examiner also found that the Veteran's migraine is not caused by or a result of exposure to contaminated water at Camp Lejeune. See July 2022 contaminated water opinion.

The matter came before the Board for in January 2023, when the Board found that the claim for service connection for migraine headaches is intertwined with the claim for service connection for an acquired psychiatric disorder; therefore, the Board remanded the matter. See January 2023 BVA Decision. The Board instructed that if the examiner determines that the acquired psychiatric disorder is related to military service, the examiner should
 Veteran's migraines were less likely than not aggravated i.e., worsened beyond its natural progression by her service-connected disabilities. See June 20222 aggravation opinion. The examiner also found that the Veteran's migraine is not caused by or a result of exposure to contaminated water at Camp Lejeune. See July 2022 contaminated water opinion.

The matter came before the Board for in January 2023, when the Board found that the claim for service connection for migraine headaches is intertwined with the claim for service connection for an acquired psychiatric disorder; therefore, the Board remanded the matter. See January 2023 BVA Decision. The Board instructed that if the examiner determines that the acquired psychiatric disorder is related to military service, the examiner should provide an opinion as to whether it is at least as likely as not that headaches are proximately due to or aggravated by the Veteran's acquired psychiatric condition.

The Veteran was given a new in-person Compensation & Pension (C&P) examination in May 2023. See May 2023 C&P Exam. The May 2023 examiner found that the Veteran's headaches are less likely than not related to her PTSD. See June 2023 secondary opinion. The examiner also found that the claimed condition was less likely than not aggravated beyond its natural progression by the Veteran's PTSD condition. See June 2023 aggravation opinion.

The RO obtained other new opinions in March and May of 2024; However, the Board found that the March and May 2024 opinions were inadequate. See March 2024 secondary opinion, March 2024 aggravation opinion, May 2024 secondary opinion, and May 2024 aggravation opinion. The Board found that the examiner did not consider all procurable and assembled data prior to reaching a conclusion. Specifically, the examiner did not address the July 2022 VA examiner's notation that migraines were associated with a psychiatric disability and triggered by psychological stress. The examiner found no objective evidence to support the Veteran's claim and stated that such a determination would be speculative. See July 2024 BVA Decision. The matter was remanded to obtain addendum opinions and provide a new VA examination.

Since the prior remand, the RO has obtained four medical opinions. 

First in September 2024, a VA examiner provided a direct negative nexus opinion. The examiner found that the Veteran's migraine headaches are less likely than not incurred in or caused by an in-service injury, event, or illness. See September 2024 direct opinion. The examiner provided the following rationale: 

Medical Evidence Taken into Consideration. The remand letter dated 7/18/2024, the Veteran's lay statements, the TERA exposures, and the VA examiner's notation in July 2022 that migraines were associated with a psychiatric disability and triggered by psychological stress were reviewed and acknowledged. The claimed migraine including migraine variants condition was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. I reviewed the 3447 page e-file and cited specific records of interest. I found no record of chronic or recurrent migraine problems beginning in the service. No recurrent migraine or headaches noted in the STR or immediate post-separation period.

Although the Veteran reports that migraines began approximately 35 years ago, shortly after service, this account is not supported by any clinical documentation from the service or immediately following discharge. I have reviewed and acknowledge the veteran's lay statements. However, multiple questionnaires and objective evidence from the period of service clearly and unmistakably show the vet categorically denied having headache pain. I cannot overlook such indisputable and clear objective evidence in favor of her subjective statements made decades after separation in order to establish a nexus for service connection.

A nexus for service connection requires evidence of chronicity, which is lacking in this case. While migraines can indeed be associated with psychological stress, as noted in prior evaluations, the connection to the Veteran's service cannot be established without documented evidence of chronic headaches beginning during service.

Furthermore, the prior examiner's remarks, indicating that migraines are often idiopathic with various potential triggers, reinforce the conclusion that the connection to service remains speculative. There are no findings in the STRs or subsequent medical evaluations that directly associate the Veteran's migraines with her military service.

I reviewed the VA examiner's notation in July 2022 that migraines were associated with a psychiatric disability and triggered by psychological stress however there is only a correlative link not a causal one. Correlation is not causation. Although PTSD can be a potential risk factor for migraines, there is no evidence in the entire efile that the PTSD, TERA exposure, or any other in service event or service-connected condition caused the migraine including migraine variants. Therefore, a nexus for service connection for the migraine including migraine variants condition cannot be established.

The September 2024 VA examiner also found that
 to service remains speculative. There are no findings in the STRs or subsequent medical evaluations that directly associate the Veteran's migraines with her military service.

I reviewed the VA examiner's notation in July 2022 that migraines were associated with a psychiatric disability and triggered by psychological stress however there is only a correlative link not a causal one. Correlation is not causation. Although PTSD can be a potential risk factor for migraines, there is no evidence in the entire efile that the PTSD, TERA exposure, or any other in service event or service-connected condition caused the migraine including migraine variants. Therefore, a nexus for service connection for the migraine including migraine variants condition cannot be established.

The September 2024 VA examiner also found that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected condition. See September 2024 secondary opinion. The examiner provided the following rationale: 

Medical Evidence Taken into Consideration. The remand letter dated 7/18/2024, the Veteran's lay statements, the TERA exposures, and the VA examiner's notation in July 2022 that migraines were associated with a psychiatric disability and triggered by psychological stress were reviewed and acknowledged.

The claimed Migraine including migraine variants condition is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of service-connected PTSD with bruxism previously addressed as acquired psychiatric disorder. The vast majority of migraines are idiopathic with completely unexplained causes. The condition is occasionally vascular in nature, hormonal, emotional, genetics, medication related, due to OSA or CPAP use, due to brain lesions/masses or many other causes. In vets' case her migraine condition can be due to hormonal changes. Hormonal changes in women causes fluctuations in estrogen levels especially during menstrual cycles, pregnancy and menopause are a common triggers for migraine in women. As to the VA examiner's notation in July 2022 that migraines were associated with a psychiatric disability and triggered by psychological stress, while it is true that emotional stress or anxiety can trigger migraine. It also depends upon the severity, level and frequency of stress that would result to migraine. Usually, stress is not continuous so as to cause or trigger migraine as compared to hormonal changes that frequently happens in women. Hormonal changes triggering migraine is a stronger risk factor as compared to PTSD with bruxism. I see no supportive documentation in the e-file or the evidence specifically noted above to support such a connection. Attributing the migraines to PTSD with bruxism without objective evidence would be entirely speculative.

The September 2024 examiner also found that the claimed migraines condition was less likely than not aggravated by the Veteran's service-connected PTSD and bruxism condition. See September 2024 aggravation opinion. 

The September 2024 examiner also found that the claimed condition was less likely than not caused by the indicated Toxic Exposure Risk Activities (TERA). See September 2024 TERA opinion. 

In sum, service connection cannot be granted on a direct or secondary basis. Presumptive service connection due to exposure to Contaminants in Camp Lejeune Water Supply is not available for migraines because migraine headaches are not listed under 38 CFR 3.309(f). 

(CONTINUED ON NEXT PAGE.)

?

Accordingly, the Board finds that the evidence weighs against a finding of service connection and that the evidence is not in approximate balance, nor 'nearly equal.' The Veteran's conditions are not causally or etiologically related to active-duty service. As such, the doctrine of reasonable doubt does not apply, and the Veteran's claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021).

 

 

Paulette Vance Burton

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Gaminchi, Yasmin

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.