SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

S. MERRICK · 2026 · Case ID: A26019357

GRANTED

Summary

The veteran, who served from November 1986 to January 1990, appeals the denial of service connection for obstructive sleep apnea and migraine headaches. The Board found that the veteran's obstructive sleep apnea was directly related to service, granting service connection. The veteran's lay testimony regarding in-service sleep-related symptoms and his wife's testimony about his snoring and breathing cessation were found credible. The Board afforded significant weight to a private treating physician's opinion, which stated a high probability that the sleep apnea developed or was significantly aggravated during service, noting that in-service symptoms were misattributed to chronic back pain. This opinion was supported by medical literature and the veteran's treatment records. The VA examiners' opinions, which found no nexus to service or service-connected disabilities, were given little probative value due to a lack of reasoning. Service connection for obstructive sleep apnea was granted on a direct basis. For migraine headaches, the Board found the evidence in approximate balance, granting secondary service connection. The veteran claimed migraines were caused or aggravated by his service-connected low back pain. While service treatment records were silent, post-service records showed a history of migraines, with the veteran reporting onset in 1987. A private treating physician opined the migraines were 100% likely caused by the service-connected low back pain, citing medical literature on chronic pain and migraines. VA examiners found no nexus between migraines and the back condition or its treatment. The Board found the private opinions persuasive, particularly given the veteran's testimony about in-service headaches and subsequent treatment delay, and applied the benefit of the doubt doctrine, granting secondary service connection for migraines.

Rationale

Favorable private treating physician opinion; Credible lay testimony regarding in-service symptoms; Medical literature supports link

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210413-153176

Full Decision Text

Citation Nr: A26019357
Decision Date: 03/04/26 Archive Date: 03/04/26

DOCKET NO. 210413-153176
DATE: March 4, 2026

ORDER

Entitlement to service connection for obstructive sleep apnea is granted.

Entitlement to secondary service connection for migraine headaches is granted.

FINDINGS OF FACT

1. The Veteran's obstructive apnea had an onset in service.

2. The Veteran's migraine headaches are caused by his service-connected lower back pain.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for entitlement to secondary service connection for migraine headaches have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 4.125.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from November 1986 to January 1990.

Although the Veteran initially requested Higher-Level Review when submitting the March 2020 VA Form 20-0996, Decision Review Request: Higher-Level Review, the Higher-Level Reviewer determined that there had been a duty to assist error and transferred the claim to the Supplemental Claim decision review option for additional development.

In the April 13, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on June 30, 2025. Therefore, the Board may only consider the evidence of record at the time of the October 2020 rating decision, as well as any evidence submitted by the Veteran at the hearing or within 90 days following the hearing. 38 C.F.R. §?20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the October 2020 rating and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted and the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included in this decision.

Service Connection

Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Alternatively, service connection may also be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Secondary service connection may be established by a showing that a nonservice-connected disability is caused or aggravated (worsened) by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4 th 776, 781 (Fed. Cir. 2021).

1. Entitlement to service connection for obstructive sleep apnea

The Veteran contends that his obstructive sleep apnea had its onset in service.
a showing that a nonservice-connected disability is caused or aggravated (worsened) by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).

1. Entitlement to service connection for obstructive sleep apnea

The Veteran contends that his obstructive sleep apnea had its onset in service. Alternatively, the Veteran contends that his sleep apnea was caused or aggravated by his service-connected chronic low back pain, including medications used to treat the disability.

Service treatment records are silent for treatment, symptoms, or complaints of sleep apnea.

Post-service treatment records reflect a diagnosis of sleep apnea requiring the use of a CPAP machine in November 2019.

The Veteran submitted an opinion from his private treating physician in December 2019. The physician opined that the Veteran's obstructive sleep apnea was caused by his service-connected injury. The Veteran's sleep study was attached.

The Veteran submitted medical articles in February 2020. The Veteran submitted excerpts describing drug-induced apnea from taking opiod medications for pain. A Medscape article discusses the association between obstructive sleep apnea and chronic pain. An article from the Journal of Physical Therapy Science discusses the relationship between sleep disorders and pain levels.

In a March 2020 VA opinion, the examiner opined that the Veteran's obstructive sleep apnea was less likely than not caused or aggravated by his service-connected lower back pain. The examiner stated there was no current research or evidence to support the relationship between obstructive sleep apnea and post-traumatic low back pain with myofascial syndrome.

In a September 2020 VA opinion, the examiner stated that there is no evidence to support the finding that the Veteran's sleep apnea was aggravated by his service-connected disabilities. The examiner reviewed the private opinion from Dr. Brown, which stated that the Veteran's sleep apnea worsened due to medication use. The examiner stated that there was no peer-reviewed literature to support the finding that Veteran's medication caused or aggravated his sleep apnea nor support any relationship between his service-connected disabilities and sleep apnea. The examiner did not review or discuss the articles submitted by the Veteran.

During a June 2025 Board hearing, the Veteran and his wife testified before the undersigned regarding the onset of sleep apnea. Following his service-connected back injury, the Veteran recalled being unable to maintain a healthy weight as a result of his limited mobility. Reportedly, he weighed around 350 pounds at his heaviest weight. The Veteran's wife recalled his initial symptoms of snoring and stopping breathing in his sleep around 2015. The Veteran sought treatment from his physician, Dr. Brown, who conducted a sleep study and diagnosed obstructive sleep apnea in November 2019.

Within the evidentiary window, the Veteran submitted an opinion from his treating physician, Dr. Brown, in June 2025. The Veteran's sleep apnea was diagnosed via sleep study in November 2019. Prior to the sleep study, the Veteran reported experiencing symptoms of excess daytime fatigue, snoring, and difficulty concentrating; his symptoms were misattributed to his service-connected lower back disability. The physician stated that sleep apnea can be exacerbated by physical and mental stress associated with military service. Additionally, the physician stated that his in-service symptoms were viewed as symptoms associated with his chronic lower back pain. Though his sleep apnea was not formally diagnosed until 2019, the physician stated that it is "highly probable" the Veteran's sleep apnea developed or was significantly aggravated during service.

Based on a review of the record, the Board finds the evidence in favor of the Veteran. The October 2020 rating decision on appeal favorably found that the Veteran had a diagnosis of obstructive sleep apnea. Additionally, the Board finds the Veteran's report of in-service symptoms credible satisfying the requirement of an in-service event, injury, or occurrence. Therefore, the remaining issue before the Board addressing the theory of direct service connection is whether a nexus exists.

The Board finds the Veteran competent to report that he experienced sleep-related symptoms both in service and since separation. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a veteran is competent to testify regarding continuous pain since service, and lay evidence, when credible, is competent to establish the presence of continuous symptoms for a claimed disability during and since separation from military service); Buchanan v. Nicholson, 451
nea. Additionally, the Board finds the Veteran's report of in-service symptoms credible satisfying the requirement of an in-service event, injury, or occurrence. Therefore, the remaining issue before the Board addressing the theory of direct service connection is whether a nexus exists.

The Board finds the Veteran competent to report that he experienced sleep-related symptoms both in service and since separation. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a veteran is competent to testify regarding continuous pain since service, and lay evidence, when credible, is competent to establish the presence of continuous symptoms for a claimed disability during and since separation from military service); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (holding that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). Additionally, the Board finds the Veteran's wife competent to report her observations of snoring and stopping breathing.

The Board acknowledges that the only opinion addressing the theory of direct service connection is the private opinion received during the evidentiary window in June 2025. Dr. Brown had treated the Veteran for years and diagnosed him with obstructive sleep apnea via a sleep study in November 2019. Despite the Veteran being formally diagnosed decades after service, the physician opined that there was a high probability the Veteran's in-service symptoms were as result of sleep apnea. The physician noted that the Veteran's sleep disturbance symptoms were mistreated for years and attributed to his chronic back pain. The physician's opinion was corroborated by the Veteran's treatment records, lay statements, and available medical literature. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Review of the file does not substitute for a lack of a reasoned analysis. Id.; See also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[a] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Board affords the private opinion of Dr. Brown probative value. The VA opinions of the records do not address the theory of direct service connection.

As the Board is granting the Veteran's claim on a direct basis, the Board does not need to address the theory of secondary service connection nor address the adequacy of the evidence presented. The evidence is persuasively in the Veteran's favor and entitlement to service connection for sleep apnea is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2. Entitlement to service connection for migraine headaches

The Veteran contends that his migraines were caused or aggravated by his service-connected chronic low back pain, including medications used to treat the disability.

Service treatment records are silent for treatment, symptoms, or complaints of headaches.

Post-service treatment records reflect a history of migraines. In February 2020, the Veteran reported an onset of migraines in 1987 following an in-service incident.

The Veteran submitted a private opinion from his treating physician, Dr. Brown, in February 2020. The physician noted a diagnosis of migraines, including migraine variants. The Veteran reported symptoms in service when placed in small, confined spaces on the ship but did not seek treatment due to high alert conditions. The physician stated that the medications taken for headaches led to a secondary disturbance. The Veteran's symptoms were also provoked when recalling military experiences. The physician opined that the probability that his migraines resulted from his service-connected disability is "100% likely."

The Veteran submitted medical articles in February 2020. An article from an orthopedic physician discusses the relationship between spine injuries and migraines. A case study from The Mental Health Clinician discusses the management of migraine headaches in a chronic pain patient. The study describes the impact of medication used for chronic pain on migraines and masking triggers.

In a March 2020 VA opinion, the examiner opined that the Veteran's migraines were less likely than not caused or aggravated by his service-connected lower back pain. The examiner stated there was no current research or evidence to support the relationship between migraines and post-traumatic low back pain with myofascial syndrome.

In a September 2020 VA opinion, the examiner stated that there is no evidence to support the finding that the Veteran's migraines were aggravated by his service-connected disabilities. The examiner reviewed the private opinion from Dr. Brown, which stated that the Veteran's migraines worsened due to medication use. The examiner stated that there was no peer-reviewed literature to support a finding that Veteran's medication caused or aggravated his migraines nor support any relationship between his service-connected disabilities and migraines.
Veteran's migraines were less likely than not caused or aggravated by his service-connected lower back pain. The examiner stated there was no current research or evidence to support the relationship between migraines and post-traumatic low back pain with myofascial syndrome.

In a September 2020 VA opinion, the examiner stated that there is no evidence to support the finding that the Veteran's migraines were aggravated by his service-connected disabilities. The examiner reviewed the private opinion from Dr. Brown, which stated that the Veteran's migraines worsened due to medication use. The examiner stated that there was no peer-reviewed literature to support a finding that Veteran's medication caused or aggravated his migraines nor support any relationship between his service-connected disabilities and migraines. The examiner did not review or discuss the article submitted by the Veteran.

During a June 2025 Board hearing, the Veteran and his wife testified before the undersigned regarding the onset of his migraine headaches. The Veteran recalled his in-service duties as a boiler tech included maintaining, inspecting, and repairing pumps, boilers, and valves located at the bottom of the ship. His work environment included very confined spaces between 110 to 120 degrees. The Veteran recalled first experiencing migraines in 1988 while stationed in the Persian Gulf under hostile territory; he was stuck in general quarters for 122 days with limited food after the USS Stark got hit by a missile. The Veteran recalled first seeking treatment for his migraines in 2018 from Dr. Brown. He reported that his physician attributed his migraines to chronic pain from his service-connected lower back disability. The Veteran believed his migraines were caused by a combination of his in-service work environment and his chronic back pain. The Veteran acknowledged the delay in seeking medical treatment after separation because he was self-medicating with over-the-counter medications. Prior to his back injury in 1988, the Veteran did not recall experiencing any migraines.

The Veteran submitted an opinion from his private treating physician, Dr. Brown, during the evidentiary window in June 2025. The physician opined that the Veteran's migraines were caused by his service-connected lower back pain. The physician stated that the connection between chronic pain and the development of secondary conditions, including migraines, is well established in medical literature. Chronic pain can lead to significant neurologic changes and alterations in pain processing, which contribute to the onset and exacerbation of secondary disabilities, like migraines. The brain becomes hypersensitive to pain signals and potentially triggering migraines in individuals with preexisting muscular skeletal pain. The physician stated that there is a "clear nexus" between the Veteran's chronic lower back pain and the development of his migraines. Additionally, the physician opined that the Veteran's migraines were likely exacerbated by persistent and chronic pain.

At the outset, the Board finds that service connection is not warranted on a direct basis. The Board also acknowledges that the Veteran did not raise the theory of direct service connection. The Board also acknowledges that the Veteran reported experiencing headaches while deployed aboard ship but did not seek treatment due to high stress circumstances. However, the Veteran did not report experiencing headaches continuously since separation. The Board notes that, although not a dispositive factor, the passage of time between the Veteran's discharge and an initial diagnosis along with a lack of treatment for the claimed disorder is one factor that weighs against the Veteran's claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Direct service connection for migraines is not warranted.

Turning to the issue of secondary service connection, the Board finds that the evidence is, at least, in approximate balance as to whether the Veteran's migraines were caused by his service-connected chronic low back pain. The most persuasive evidence in favor of the claim is the February 2020 and June 2025 private opinions from Dr. Brown. Both opinions noted that his chronic lower back pain can cause neurologic changes leading to headaches. The physician also stated that the opiod medications used to treat the Veteran's chronic pain can cause headaches. Additionally, the Veteran submitted medical articles discussing the correlation between chronic pain and migraines. The Board affords this evidence probative value.

The unfavorable evidence consists of the March 2020 and September 2020 VA examiner's opinion. The Board acknowledges that the examiner reviewed the Veteran's treatment records, including the opinion provided by Dr. Brown. However, the examiner did not provide any reasoning or basis for the opinion. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (stating that a medical opinion must support its conclusion with an analysis that the Board can weigh, and a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision). The Board affords these decisions little probative value.

For the above reasons, the Board finds
The Board affords this evidence probative value.

For the above reasons, the Board finds that the evidence is in approximate balance as to whether the Veteran's service-connected chronic lower back pain caused his migraines. Consequently, service connection is warranted. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

S. Merrick

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Clevenger, Gordanna A.

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.

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