Citation Nr: 0001958 Decision Date: 01/24/00 Archive Date: 03/02/00 DOCKET NO. 95-29 745 DATE JAN 24, 2000 On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for a claimed headache disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Julie L. Salas, Associate Counsel INTRODUCTION The veteran served on active duty from March 1964 to March 1967. This matter initially came to the Board of Veterans' Appeals (Board) on appeal of a May 1994 rating decision of the RO. The Board remanded this case for additional development of the record in April 1997 and February 1999. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. 2. The veteran has submitted evidence which suggests that his claim of service connection for headaches is plausible. CONCLUSION OF LAW The veteran has presented a well-grounded claim of service connection for a headache disorder. 38 U.S.C.A. 1101, 1110, 1112, 1113, 1131, 1137, 5107, 7104 (West 1991 & Supp. 1999); 38 C.F.R. 3.303 (1999). - 2 - REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim is plausible and capable of substantiation, and thus well grounded within the meaning of 38 U.S.C.A. 5107(a). When a veteran submits a well-grounded claim, VA must assist him in developing facts pertinent to the claim. 38 U.S.C.A. 5107(a). The Board is satisfied that all available relevant evidence has been obtained regarding the claim, and that no further assistance to the appellant is required to comply with 38 U.S.C.A. 5107(a). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. 1131; 38 C.F.R. 3.303. The regulations also provide that service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. 3.303(d). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). A care review of the veteran's service medical records shows that they are negative for any treatment of headaches in service; however, at the discharge examination, the veteran noted a history of having had frequent or severe headaches. Private treatment reports from the Hamot Medical Center in Erie, Pennsylvania, noted that, in December 1978, the veteran was hospitalized for evaluation of a temporary loss of vision associated with a slight headache. The discharge diagnosis - 3 - was that of temporary loss of vision, etiology undetermined. Subsequently, in February 1979, the veteran underwent a CT scan for the same complaints of temporary loss of vision associated with slight headaches. The CT scan was stated to be negative. VA outpatient treatment reports submitted in support of the veteran's claim included notations to the effect that the veteran had reported for treatment in August 1986 for "spells" of vision disturbance. At that time, the veteran reported that he had been suffering such "spells" since 2 months after returning from the Republic of Vietnam in 1966. The final assessment was that the veteran was possibly suffering from an ocular migraine condition. He also received treatment in November 1990 for headaches occurring 2 to 3 times per week, described as unilateral and retroorbital in nature with radiation laterally to the occipital area. According to the veteran, he had been suffering from headaches for a period in excess of 20 years. The final diagnosis was that of migraine headaches. In April 1994, the veteran underwent a VA examination. At that time, the veteran presented with complaints of constant headaches in the region of his forehead, behind the eyes, and in the back of his neck, accompanied by occasional nausea and rare vomiting. He further reported that the pain was not relieved with over-the- counter pain medications. The final diagnoses included that of headaches. Based on its review of the record as a whole, the Board finds that the veteran has presented evidence sufficient to show that his claim of service connection for a headache condition is plausible. The Board notes that the record documents that the veteran presented for treatment of visual disturbances associated with slight headaches as early as 1978, which were subsequently identified as potential ocular migraines. Furthermore, the Board emphasizes that at those times when the veteran supplied a history of his headache condition prior to submission of his claim in 1993, he reported a duration of time that would have placed their inception in service. He also related a credible history of having developed frequent and severe headaches - 4 - prior to his discharge from service. Thus, the Board finds that the veteran has submitted a well-grounded claim of service connection for a headache disorder. ORDER As a well-grounded claim of service connection for a headache disorder has been submitted, the appeal to this extent is allowed, subject to further action as discussed hereinbelow. REMAND In light of the fact that a well-grounded claim of service connection has been presented by the veteran, the Board finds that further development is required prior to appellate handling of this matter. To ensure that VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The RO should take appropriate steps to contact the veteran in order to again afford him another opportunity to provide the names and addresses of any other medical care providers who have treated him for his claimed headache disorder since service. After securing the necessary release, the RO should obtain copies of all records from any identified treatment source. 2. The veteran then should be afforded a VA examination to determine the nature and likely etiology - 5 - of the claimed headache disorder. The claims folder should be made available to the examiner for review in connection with the evaluation. All indicated testing should be done in this regard. The examiner should elicit from the veteran and record a full medical history referable to his headaches and any related manifestations. Detailed clinical findings also should recorded. Based on his/her review of the case, the examiner should offer an opinion as to the medical probability that the veteran has current headache disability due to disease or injury which was incurred in or aggravated by service. 3. After the development requested above has been completed, the RO should again review the veteran's claim. If any benefit sought on appeal remains denied, the veteran and his representative should be furnished with a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The veteran need take no action unless otherwise notified. The veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, 302, 108 Stat. 4645, - 6 - 4658 (1994), 38 U.S.C.A. 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, pares. 8.44-8.45 and 38.02-38.03. STEPHEN L. WILKINS Member, Board of Veterans' Appeals 7 -