RECORD OF PROCEEDINGS

	IN THE CASE OF:       

	BOARD DATE:            26 AUGUST 2004                  
	DOCKET NUMBER:   AR2003096162

	I certify that hereinafter is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in the case of the above-named individual.  

	Mr. Carl W. S. Chun		Director	
	Mr. Kenneth H. Aucock		Analyst	

  The following members, a quorum, were present:

	Mr. Raymond Wagner		Chairperson	
	Mr. Lester Echols		Member	
	Ms. Margaret Thompson		Member	

	The applicant and counsel if any, did not appear before the Board.

	The Board considered the following evidence:

	Exhibit A - Application for correction of military records.

	Exhibit B - Military Personnel Records (including advisory opinion, if any).

THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE:  

1.  The applicant requests physical disability retirement.

2.  The applicant made no statement, but deferred to counsel.

3.  The applicant provides copies of her medical records, to include Medical 
Evaluation Board (MEB) and Physical Evaluation Board (PEB) proceedings.

COUNSEL'S REQUEST, STATEMENT AND EVIDENCE: 

1.  Counsel requests that the applicant's records be corrected to show that she was retired from the Army because of physical disability with a 60 percent disability rating.  

2.  Counsel states that the applicant does not dispute the finding that she was unfit, however, contends that the PEB and the Physical Disability Agency misapplied VASRD (Department of Veterans Affairs Schedule for Rating Disabilities) disability codes and violated provisions of Army Regulation 635-40, resulting in her receiving a 20 percent disability rather than 60 percent rating. 

a.  Counsel states that the applicant was satisfied with the 40 percent rating awarded by the 3 March 2003 informal PEB, 30 percent due to migraine headaches, VASRD code 8100, and 10 percent due to conversion disorder, VASRD 9424; however, the PEB changed the rating by substituting VASRD code 8045, post-concussive headaches for code 8100 resulting in a new disability rating of 10 percent, lowering her total disability to 20 percent, leaving her entitled only to a lump sum disability benefit of less than $750.00.  The applicant then demanded a formal hearing.  The formal PEB affirmed the 20 percent rating, and rejected her rebuttal.  The Physical Disability Agency agreed with the PEB ratings.  The applicant was discharged from the Army.

b.  Counsel states that the applicant's medical records overwhelmingly establish that she has migraine headaches, that a mistake of law occurred by the PEB's use of code 8045 rather than 8100 on the basis that her migraine headaches were caused by head trauma, that the medical records do not clearly establish head trauma as the cause of her migraines, and that the Army violated Army Regulation 635-40 by failing to give her the benefit of the doubt, and by failing to consider the overall effect of all her disabilities.   	

c.  Counsel sates that the applicant was repeatedly diagnosed with migraine headaches, the first diagnosis made some years prior to the PEB hearing.  Days before the formal hearing, the applicant's neurologist strongly reiterated that she had migraines.  Her symptoms as shown in her medical records clearly demonstrated that she met the functional impairment criteria for 30 percent as originally determined by the PEB.  She has required hospitalization, narcotic medications, and has been unable to perform her duties for days at a time due to her migraine headaches. 

d.  Counsel states that the Army is legally mistaken in believing that the cause of her headaches must be considered in determining what VASRD code to apply, stating that if causation were determinative, code 8100 (migraine) would contain language excluding post-concussive migraines and 8045 would contain language requiring its usage where migraines were caused by head trauma.  Army Regulation 635-40 indicates that percentage ratings should reflect the severity of the Soldier's medical condition at the time of the rating and where there is a question as to which of two percentage evaluations should be applied, the higher evaluation will be assigned if the Soldier's disability more nearly approximates the criteria for that rating.  Counsel states that it is obvious that the severity of the applicant's condition due to migraines could not be adequately rated by applying the 10 percent limit of VASRD code 8045. 

e.  Counsel states that it is speculative whether her migraine headaches were caused by trauma and therefore post-concussive, stating that she had her first migraine one month after her second documented head trauma.  Counsel states that women are more susceptible to migraines than men, apparently due to hormonal phenomena.  Her medical records show a diagnosis of endometriosis (a condition which occurs aberrantly in various locations in the pelvic cavity) which was surgically and medically addressed.  Counsel states that her headaches could possibly be related to hormonal changes associated with the menstrual cycle.

f.  Counsel states that the PEB erred in failing to follow the pyramiding rules.  The applicant has daily headaches, which were not migraine, and then at least once a month, a debilitating migraine headache.  The daily headaches began two weeks after her first documented line of duty head trauma.  It is reasonable to describe her daily headaches as post-concussive; however, her monthly migraines were likely a completely different and unrelated disease process.  Counsel states that the applicant could be properly coded for both 8045 (post-concussive) and 8100 (migraine) headaches; however, since pyramiding is prohibited, code 8100 must be used because her functional impairment is         30 percent, as reflected in the original PEB decision, a percentage not available under code 8045. 

g.  Counsel states that the PEB made a mistake in rating her disability for conversion disorder at 10 percent, stating that she meets all the criteria for a      30 percent rating.  Counsel states that the strongest evidence was the response of a psychiatrist to written questions from the applicant's military counsel.

h.  Counsel states that the medical evidence and the VASRD codes legally require a disability percentage rating of 60 percent.

CONSIDERATION OF EVIDENCE: 

1.  The available records are those submitted by the applicant.  Her military personnel records, to include her separation documents, however, are not available to the Board.  Nevertheless, it is apparent from the evidence that the applicant was an active duty Soldier who was assigned to Fort Carson, Colorado. It can be assumed that the applicant was discharged from the Army with a        20 percent disability rating, as counsel so states; otherwise, there would be no reason for the applicant's appeal to this Board.

2.  The applicant submits a voluminous amount of medical evidence, which shows that she was seen and treated for migraine headaches on numerous occasions dating from mid-1999 through mid-2003, that she was prescribed an inordinate number of medications in attempts to resolve her headaches, and that she was on quarters and hospitalized on occasions for her headaches.  The evidence also shows that she had other medical conditions which included chronic daily headaches, conversion disorder, endometriosis, depression, and carpal tunnel syndrome.

3.  Migraine as defined in Dorland's Illustrated Medical Dictionary is an often familial symptom complex of periodic attacks of vascular headache, usually temporal and unilateral in onset, commonly associated with irritability, nausea, vomiting, constipation or diarrhea, and often photophobia (abnormal visual intolerance of light).  Attacks are preceded by constriction of the cranial arteries, usually with resultant prodromal sensory (especially ocular) symptoms, and commence with the vasodilation that follows.  Army Regulation 40-501 indicates that migraine, tension, or cluster headaches, when manifested by frequent incapacitating attacks are neurological disorders and is cause for referral to an MEB. 

4.  Conversion disorder as defined in Dorland's Illustrated Medical Dictionary is a mental disorder characterized by conversion symptoms (loss or alteration of physical function suggesting physical illness, usually of the sensorimoter system, such as seizures, paralysis, blindness) having no physiological basis and whose psychological basis is suggested by exacerbation of symptoms at times of psychological stress, relief from tension or inner conflicts (primary gain) provided by the symptoms, or secondary gains (support, attention, avoidance of unpleasant responsibilities) provided by the symptoms.  Many patients exhibit a lack of concern about the impairment caused by the symptoms; histrionic (hysterical) personality traits are also common.    

 5.  The applicant experienced trauma to her head on five occasions, on              15 May 1999 when she fell down a hill and injured her head while participating in a field training exercise, in February 2000 when a tent frame fell on her head, in May 2000 while snow sledding when she fell out of an inner tube hitting her head on a rock, in June 2001 when an artillery simulator went off and struck her in the head, and on 18 November 2002 when she struck her head against a chair and the floor while getting out of her hospital bed at Walter Reed Army Medical Center (WRAMC).

6.  The applicant's medical records show:

a.  On 19 May 1999 the applicant had complained of headaches for the past five days.  That record shows that the applicant had fallen and hit the front of her head and was seen in the emergency room.  Since then she had experienced frontal-temporal headaches.  She was diagnosed as having post concussion headaches.  On 9 July 1999 the applicant was evaluated for headaches.  On 13 July 1999 she was seen because of nausea, and because she was vomiting.  On 1 September 1999 she complained of headaches.
 
 	b.  A 7 December 1999 Mental Health Service, Evans Army Community Hospital, Fort Carson, Colorado narrative summary indicates that the applicant was admitted to the hospital on 7 December 1999 to evaluate suicidal ideation.  Her past medical history indicated that she had a head concussion in May of 1999 and was in biofeedback for an unspecified time.  She also had anaphylactic shock in basic training after a meal but it was unclear what precipitated the reaction.  Her condition was diagnosed as depressive disorder, not otherwise specified, personality disorder not otherwise specified with borderline traits, acne, and psychosocial stressors.

	c.  The applicant was seen by a staff psychologist at Peterson Air Force Base in Colorado on 16 December 1999, after having been referred for a psychological evaluation at the request of Fort Carson, because of suicidal thoughts.  The applicant reported having numerous psychosocial stressors since June 1999.  She reported increased fatigue and decreased energy since June 1999, and reported decreased concentration and increased headaches since a May 1999 head injury.  Her condition was diagnosed as adjustment disorder with mixed anxiety and depressed mood, and relational problems not otherwise specified; and a head injury in May 1999 (per the applicant).

	d.  She was seen on 12 May 2000 because of complaints of headaches and dizziness in a clinic at Fort Carson.  She was referred to family practice because of headaches and a dilated pupil.  On 9 August 2000 the applicant complained of pain in the lower right side of her stomach.  On 25 August 2000 she complained of headache, pain in lower right side, nausea, and vomiting.  On 5 September 2000 the applicant complained of headache, nausea, vomiting, and sinusitis.

	e.  On 13 December 2000 the applicant underwent a diagnostic laparoscopy because of chronic pelvic pain.  Her postoperative diagnosis was endometriosis.  On 13 March 2001 she was followed up for endometriosis.  The applicant stated that she was having increased pain.

	f.  On 14 March 2001 the applicant was diagnosed as having migraines. 

g.  On 15 March 2001 she complained of having a headache for two days.  She was placed on quarters.  On 16 March 2001 the applicant was seen because of a chronic migraine headache.  The applicant stated that her last migraine was three weeks ago, and that she had a bad migraine approximately once a month that lasted for 3-4 days.  An Air Force neurologist diagnosed her as having a common migraine.

h.  On 21 June 2001 the applicant underwent a CT scan of her head because she had been struck in the head with a rock from a grenade simulator.  The diagnosis was that it was a normal CT scan of her head without contrast.

	i.  A 31 July 2001 telephone consultation to a clinic at Evans indicates that the applicant called in reference to her endometriosis.  The provider indicated that she still had irregular bleeding and that she wanted to discuss her profile.  Medical records of 5 November and 19 November 2001 indicate that the applicant's medical problems were endometriosis and migraine headaches.

j.  On 20 November 2001 the applicant complained of a migraine headache, nausea/vomiting, and of her right eye dilating last night.  She was diagnosed as having a migraine headache.  

	k.  An 11 January 2002 telephone consultation at Evans indicates that the provider saw the applicant, and gave her the note she requested for weight gain and its association with the hormonal therapies she had been using for her endometriosis.  A 16 April 2002 telephone consultation with the psychiatry clinic at Evans indicates that the applicant would start Ultram for endometriosis, and would decrease Zoloft to 100mg per day for 1 week, and then discontinue.  Provider discussed with applicant.  A 17 April 2002 telephone consultation at the GYN clinic at Evans indicates that the applicant wanted to stop certain medications, as she felt not terribly helpful for endometriosis pain.  She wanted to consider laparoscopy with ablation.  Her medical provider, an Army doctor, discussed with her that it was reasonable if her pain became more severe after she stopped the medications.  He told her to give it a 1-3 month trial.
 
	l.  On 9 May 2002 she was placed on quarters for 72 hours because of a headache and a sore tooth.  A 13 May 2002 telephone consultation with the neurology clinic, Air Force Academy hospital, indicates that the applicant had daily headaches and was only on ammerge for migraines.  The clerk questioned whether she could be started on a prophylactic for her daily headaches.  The provider, an Air Force doctor, stated that he would try a trial of Depakote, and indicated that he asked her to see him in three to four weeks.  A 14 May 2002 sick slip shows that the applicant had a migraine headache and nausea/vomiting. She was placed on quarters that day.

7.  In a 10 June 2002 statement to the Physical Evaluation Board at Fort Lewis, the applicant's executive officer stated that the applicant had been involved in various activities with the unit.  She, the executive officer, stated that upon arriving at the 2nd Medical Detachment, the applicant was recovering from surgery.  She began with a limiting physical profile and passed the Army Physical Fitness Test.  She participated in the physical fitness program, within the limitations of her profile, and exercised at the gym in the evening.  She made great strides in improving her physical fitness and continuously kept in touch with her doctors to decrease her limitations.  Her physical limitations dictated by her profile did not affect her great work at the 2nd Medial Detachment.  She earned two Army Achievement Medals while on the team.  She would continue to provide the Army with excellent job performance.

8.  In a 27 June 2002 report of medical examination, a doctor diagnosed her condition as posttraumatic migraines, endometriosis, bursitis of her right hip, and pes planus.  A 27 June 2002 MRI (magnetic resonance imaging) of her head indicated normal intracranial contents.

9.  A 5 August 2002 medical record report shows that she was first seen by mental health in November 1999.  She was newly arrived at Fort Carson and had been having some stressors with difficulties related to her family.  She was admitted with some suicidal ideation, although she had not made a suicidal attempt.  She was hospitalized for a few days and then discharged with a plan of outpatient counseling.  She was seen for approximately eight months and then transferred to the care of a chaplain in September 2000.  Her medication included Zoloft.  She had a combination of individual treatment by a social worker and then a chaplain throughout most of 2000 and the early part of 2001, mainly to address personal issues without any significant difficulties that affected her performance or her abilities to function as an active duty Soldier.  She has had significant ongoing difficulties with pain associated with gynecologic problems for which the MEB was being initiated.  The report indicates that the applicant's condition was diagnosed as major depression, recurrent, moderate, manifested by dysphoria, crying spells, anhedonia, lack of motivation, decreased energy, difficulties with attention, focus, and concentration.  Her stress was moderate.  She had a history of ongoing depressive moderate depressive symptoms for two years.  Her psychosocial stressor included physical discomfort, the pending medical evaluation board, and occupational problems.  The examining physician stated that her current psychiatric condition was not unfitting for the purposes of continued military service.  She did have ongoing depressive symptoms that have been well treated with medication management. 

10.  She was seen at the emergency room on 7 August 2002 "because of the worst headaches of her life."  She was hospitalized and discharged from the hospital on 10 August 2002.

11.  On 7 August 2002 the applicant under went a CT (computed tomography) of her head without contrast, because she had complained of having the worst headache of her life and of an enlarged right pupil since last night.  The impression given was that there was no evidence of intracranial hemorrhage or mass.

12.  A 20 August 2002 medical record report shows that she had early bilateral wrist carpal tunnel syndrome, somewhat improved with occupational therapy. 

13.  On 23 August 2002 the applicant was seen because of daily headaches.  A 7 September 2002 medical report shows that she complained of daily migraine headaches and that she was hospitalized last month for pain control.

14.  In a 17 September 2002 statement to the Physical Evaluation Board at Fort Lewis, Washington, the applicant's commanding officer stated that the applicant had been assigned to the 10th Combat Support Hospital at Fort Carson since November 1999 and that her current profile did not allow her to perform many of her combat duties as a mental health specialist.  She could not perform the duties required in a combat stress detachment or go to the field, but was capable of all her tasks in a medical activity.  He stated that the applicant had sustained four different head injuries during her time in the Army, and she had developed a rare type of migraine headache that lasted for many days and could not be alleviated by medications.  She was unable to participate in the company's field exercises.  He stated that she was an effective Soldier in garrison.  He stated that she was still an asset to the military, but not in a table of organization and equipment (TOE) unit.

15.  On 23 September 2002 the applicant underwent a diagnostic laparoscopy because of chronic pelvic pain.  The surgical report indicates that she had undergone a diagnostic laparoscopy in December 2000 that showed endometriotic implants in her posterior cul-de-sac.  At that time she underwent Lupron therapy that did give her relief of her pelvic pain, however, she did not like the side effects, especially the weight gain.  As she was undergoing a medical board for her headaches, she requested that the physician perform another laparoscopy and look for any endometriotic implants that could be ablated in an attempt to relieve her of her pelvic pain.  The operative findings revealed no evidence of any endometriotic implants throughout her pelvis or abdomen.  Subsequent to the operation, the applicant was taken to the recovery room in excellent condition.

16.  A 23 September 2002 medical record report indicates that the applicant's condition was diagnosed as endometriosis and chronic pelvic pain due to endometriosis.  The reporting physician stated, however, that her pelvic pain did not require her to miss work.    

17.  A 30 September 2002 medical record report shows that the applicant was admitted to the Evans Army Community Hospital on 12 August 2002, having been discharged one or two days prior to the admission because inpatient therapy for intractable migraine headache was not beneficial.  The examining physician stated that she was in mild distress, and noted that her right pupil became dilated during her migraine headaches at times.  He stated that she was admitted for symptomatic treatment of her headache and that he had been working on management of her case with her neurologist at the 
Air Force Academy.  He stated that he did a lumbar puncture to rule out meningitis and pseudotumor cerebri.  He stated that her initial headache resolved but she developed a post spinal tap headache that prolonged her admission, requiring a blood patch.  She was discharged on 17 August 2002. 

18.  A 30 September 2002 medical record indicates that the applicant underwent a laparoscopy on 19 September to assess the progress of endometriosis.  The results showed no flare up or further progression of the disease. 

19.  On 30 September 2002 a MEB determined that the applicant should be referred to a PEB because of her migraine headaches.  She did not agree with the findings and recommendation of the board, and stated that she desired to remain on active duty.  On 15 October 2002 she submitted an appeal, refuting her commanding officer's statement.  She stated that she was currently working   4 hours a day; however, she could not take physical training and was restricted to light indoor duty.  She stated that her commander did not elaborate on what she could do functionally in her specialty, only stating that she could not go to the field.  She stated that her commander's evaluation did not accurately reflect on her – physically, mentally, or medically.  She also refutes the statement by a doctor, who stated that she denied that her chronic daily headaches kept her from doing her duties.  The applicant stated that was incorrect and that she was often unable to perform her duties because of her chronic daily headaches.  She stated that she was unable to perform any duties when she gets a migraine.  She commented on a 27 August 2002 report by another doctor, who stated that she was under significant stress and believed that stress was related to her headaches.  She stated, while true, she also believed that her headaches were a result of her four head injuries, as she did not even have daily headaches prior to her military service.  Her appeal was considered and denied, with the approving authority stating that her continuance on active duty was medically contraindicated.

20.  A 1 October 2002 consultation sheet indicates that the applicant had migraine headaches and chronic daily headaches for about 3 years and was seeing a neurologist at the Air Force Academy for her condition during that time.  She had been on various medications without success.  MRI and CT head were normal.  She was being medically discharged because she was not fit for duty because of her headaches.  She had requested a second opinion from a neurologist.  She had dilation of her right pupil during her migraine headaches.

21.  An 8 November 2002 medical record report from Evans Army Community Hospital shows that the applicant was being transferred to the inpatient neurology service at Walter Reed Army Medical Center for further evaluation and recommendation for treatment of her migraine headaches and her chronic daily headaches.  He stated that the applicant was having worsening migraine headaches that had become quite disabling and had also developed chronic daily headaches.  He stated that she had seen a psychologist for stress management and therapy in an attempt to help her headaches without success.  She had been treated for depression.  He stated that multiple abortive medications had been tried for her headaches.  He stated that her pain was severe and that she had photophobia and fairly profound nausea and vomiting with them.  She also had complete dilation and paralysis of the right pupil during the headache.  As the headache improved the dilation slowly resolved and returned to normal as her pain resolved.  He stated that her weight was           198 pounds and that neurological examinations had been unremarkable except during her headaches when she showed obvious distress and photophobia and the dilation of the right pupil.  

22.  A 13 November 2002 physical profile indicates that the applicant had a physical profile serial of 4 2 1 1 1 4, because of migraines, pelvic pain, carpal tunnel syndrome, and conversion disorder.

23.  A narrative summary and patient discharge instructions [report] shows that she was admitted to Walter Reed Army Medical Center on 13 November 2002.  She underwent various treatment and procedures, to include a brain MRI, EEG, head CT, sleep study, ophthalmology consultation, and an internal medicine consultation.  She described her headaches as "migraine," throbbing and pounding, like an explosion behind her eyes to her right temple area spreading to the rest of her head.  Prior to onset she typically had some visual changes.  Associated with her headaches were nausea and vomiting, photo/phonophobia, right sided weakness, right leg and bilateral hand numbness, neck and back pain, and sometimes increased heart rate.  Duration was typically 5-10 days.  She had daily headaches, present for 24 hours, usually the same as migraine in quality but less intense.  Her headaches began with a series of head traumas, with loss of consciousness in each incident.  At her examination, it was noted that her right eye was dilated with her headaches, and she was diagnosed as having an opthalmoplegic (paralysis of the eye muscle) headache.  The applicant had many sick call visits, emergency room visits, and hospitalizations for her headaches.  She has been treated for depression since January 2001.  She stated that she was depressed from all the pain that she was in, thinking of ways to get rid of the pain, by taking excess analgestic medications, etc.  

a.  The record shows that she was admitted after being air evacuated from Fort Carson, Colorado for a further work-up and evaluation before a medical board was determined.  Since arrival, she had appeared to be in constant pain, and had persistent complaints of headaches that were unresponsive to medications.  She developed an abnormally dilated right pupil, which remained unchanged.  An examination revealed no organic cause of anisocoria (inequality in diameter of the pupils).  She received a psychiatric consultation on                   22 November 2002 because she expressed depressive symptoms and suicidal ideation.  She was transferred to the psychiatry ward.  Afterward, she received multiple evaluations and tests from numerous specialists, to include neurologists, pulmonologists, psychiatrists, and internists.  It was felt that there was no medical reason for continued hospitalization and treatment at Walter Reed.  She suffered from intractable migraine headaches and right lower extremity weakness.  She was being treated with prophylactic medications with the hope of alleviating future pain and disability.  There was no physical explanation for her right lower extremity weakness.

b.  The inpatient psychiatry team felt that psychological factors contributed to both her headaches and lower extremity weakness.  Her psychiatric diagnoses were psychological factors affecting migraines and conversion disorder.  Conversion disorder was diagnosed as manifested by symptoms of leg weakness affecting voluntary motor functions suggesting a neurological disorder; psychological factors associated with headaches because the exacerbation of the headache was preceded by conflicts or other stressors.  The evaluating physicians believed that stress and unidentified factors played a role in both her pain and leg weakness.  Her symptoms caused clinically significant distress and impairment in occupational functioning.  They recommended a P-4 profile under psychiatry.  Her predisposition was severe, and her impairment for further military duty was marked.

c.  A 25 November 2002 report of psychiatric history and physical examination conducted at Walter Reed shows that she was transferred from neurology to psychiatry for safety concerns.  Neurology workup had all been negative.  She was depressed.  She exhibited labile behavior stating alternately that she felt suicidal and hopeless but would not kill herself.  She had been treated with multiple medications for her migraines, which resulted from four head injuries since early 1999.  All the injuries resulted in normal imaging and her subsequent headaches were diagnosed as post-concussive.  She reported symptoms of variable sleep, decreased energy and concentration for years, and decreased appetite only since Monday.  She reported a troubled history at her unit.  She had few friends and stated that the people were out to get her.   

24.  The applicant was discharged from WRAMC  on 8 December 2002 and  returned to Fort Carson.

25.  A 23 December 2002 medical report shows that the applicant was seen complaining of headaches and some chronic pelvic pain.  The examining physician diagnosed her condition as chronic daily headaches with intractable migraine cephalgia, chronic pelvic pain with a history of endometriosis, and obesity.  He also stated that the applicant appeared depressed, but that she denied any problems.  He stated that he did not have a great deal else to offer as she had tried almost all of the drugs that he would have treated her with and with her recent episode of right-sided weakness he wanted to see what her MRI showed.  He stated that he was also going to call her neurologist at the Air Force Academy and get his thoughts.  A 9 January 2003 MRI of her brain indicated a normal MRI study of the head.  There was no evidence of ischemia.

26.  Statements and narrative summaries for an MEB:

a.  On 6 February 2003 the applicant was seen by the assistant professor of neurology and ophthalmology at the University of Colorado Hospital.  He diagnosed her condition as intractable migraine headaches with and without aura, chronic daily headaches, and right hemiparesis.

b.  A medical evaluation board summary by an Air Force doctor, a neurologist, dated 14 February 2003, indicates that she was diagnosed with a moderately severe migraine headache disorder.  She failed extensive trials of suppressive and abortive therapy, and there were no further reasonable therapies to offer in hopes of alleviating her headaches.  The headaches were prolonged, severe, and incapacitating and clearly made her unfit to perform her military duties.  He stated that the MEB was overdue.  In an addendum to the summary, the doctor stated that the applicant had undergone significant evaluation and treatment since her original MEB narrative, and that based upon her Congressional complaint, she was evaluated at Walter Reed for her headache disorder.  While there, she experienced the unexplained onset of right-sided weakness and was diagnosed with conversion disorder.  Since her return, ongoing trials of suppressive medication in isolation and combination were tried in attempts to reduce her headaches.  No trials were successful.  She continued to experience 2-3 headaches per month that lasted 4-5 days each.  They were associated with severe pain, nausea, photo and sonophobia, and required her to lie in a dark room.  MRI of the brain showed no pathology to explain her ongoing weakness in the right leg.  Her exam was symmetric and there were no pathologic reflexes.  He had no neurological explanation for her leg parersis.  Concerns regarding her using mydriatic agents to cause pupil asymmetry were raised; however, the applicant denied this.  Her continuing presence of frequent, severe migraine headaches appeared to render her unfit for service.

c.  A 27 February 2003 narrative summary for an MEB provided by a staff psychiatrist at the Air Force Academy indicates that the applicant wanted a second opinion on the presence or absence of conversion disorder.  The summary commented on her evaluation and treatment at Walter Reed, stated that she returned to Colorado in a wheelchair due to reported right leg numbness and weakness, and had progressed to a walker, and then to crutches.  She had some return of sensation, increase in strength, and increased mobility in her right leg since starting physical therapy.  She had been seen by a neurologist and at a university hospital in Denver.  She did not believe that she had a conversion disorder.  She worried about job opportunities if she had a diagnosis of conversion disorder.  She did not think the diagnosis was correctly made and did not want it to follow her.  She would like to be placed on the TDRL so she could return to active duty if her headaches improved.  The psychiatrist diagnosed her condition as conversion disorder with mixed presentation and migraine headaches.  He stated that there did not seem to be any strong evidence to suggest that there was a condition other than conversion disorder to account for her physical symptoms and her case had been discussed with her neurologist.  He stated that she was likely to have a recurrence of conversion disorder in the future or develop a more extensive form of somatoform disorder in the future, and that her current reluctance to accept conversion disorder as a valid diagnosis might impede her recovery from her current episode.   

	d.  A 5 March 2003 MEB narrative summary provided by an internal medicine physician at Evans Army Community Hospital indicates that it was a physician directed MEB.  The summary indicates that she was originally referred for a medical board for migraine headaches in June 2002.  The evaluating physician stated that the board was completed 30 September 2002 and the case was referred to the Physical Evaluation Board where she was awarded a 30 percent disability and put on the TDRL for disabling migraine headaches.  There is, however, no evidence that she was placed on the TDRL.  The doctor stated that on 13 November 2002 her case was administratively terminated at the request of the medical treatment facility to allow further treatment at Walter Reed. The summary indicates that after her return to Fort Cason, she participated in physical therapy, had a repeat brain MRI, which was normal, and that she was seen in consultation by an assistant professor of neurology at a hospital, where some functional abnormalities were noted.  She followed up with her neurologist at the Air Force Academy Hospital, and received a second opinion from psychiatry regarding the diagnosis of conversion disorder, and was seen by a psychiatrist at the Air Force Academy, who concurred with the diagnosis of conversion disorder, falling below retention standards.  The physician stated that the applicant had not worked in her MOS since May 2002.  Her commander confirmed her inability to participate in field exercises.  Her mobility was compromised by the conversion disorder.  She was unable to do any strenuous physical exertion, physical training, or any military training or duty.  She did not want to continue on active duty.  According to her consultant, the prognosis for her headaches was poor, and for the conversion disorder, guarded.  The doctor diagnosed her conditions as migraine headaches, with frequent incapacitating attacks, and conversion disorder, with leg weakness affecting normal ambulation, resulting in interference with effective military performance.  The doctor stated that she was on a 4 2 1 1 1 4 profile.  She was referred to the PEB.

e.  In a 14 March 2003 statement to the Physical Evaluation Board at Fort Lewis, Washington, the applicant's commanding officer stated that the applicant had been assigned to the Medical Holding Detachment at Fort Carson since        20 September 2002 and since then there had been no change in her medical condition.  He stated that she ambulated with crutches and worked 4 hours a day.  He stated that the applicant stated that she had been getting chronic daily headaches and monthly migraine headaches that caused her to be hospitalized or on quarters for 5-10 days at a time.  He stated that she was taking various medications and went to the pain management center in Colorado Springs. 

f.  In statements dated 19 March 2003, both her platoon sergeant and command sergeant major stated that the applicant performed well and to her fullest potential within the limitations of her medical profile.  Her command sergeant major stated that the applicant desired to stay in the Army. 

27.  On 12 March 2003 a MEB (Medical Evaluation Board) determined that the applicant should be referred to a PEB (Physical Evaluation Board) because of migraine headaches, with frequent incapacitating attacks dating from 1999, and conversion disorder, with leg weakness affecting normal ambulation dating from 2002.  The MEB noted that she had other conditions that met retention standards – psychological factors affecting migraine headaches; chronic pelvic pain, requiring limitation in running; bilateral wrist carpal tunnel syndrome, requiring further treatment and limiting pushups; bursitis right hip, intermittently, symptomatic; and pes planus, asymptomatic.  The proceeding indicated that the applicant desired to continue on active duty; however, the MEB indicated that her continuance on active duty was medically contraindicated.  The findings and recommendations of the board were approved on 13 March 2003.  The applicant disagreed and submitted an appeal.

28.  On 20 March 2003 the approving authority indicated that her appeal had been considered, but the original findings and recommendations were confirmed. He stated that the applicant was non-deployable and that she had significant physical limitations with psychiatric overlay and that retention was not reasonable.

29.  On 28 March 2003 a Physical Evaluation Board determined that her migraine headaches following several head injuries, including one caused by a rock thrown by an artillery simulator, had apparently progressed from post concussive headaches to common migraine.  The board indicated that her condition had remained unresponsive to a large variety of prophylactic and abortive treatments, and that they occurred on an average of once or twice a month, lasting several days, and requiring bed rest and or hospitalization.  The board determined her condition was 30 percent disabling under VASRD code 8100.  The board also determined that her conversion disorder manifested by mild right lower extremity weakness without evidence of muscular atrophy with normal brain and spinal MRI interfered with common Soldier tasks and was       10 percent disabling under VASRD code 9424.  The board stated that both conditions remained unstable for adjudicative purposes, and recommended that the applicant be placed on the temporary disability retired list with a 40 percent disability rating.  The applicant concurred.

30.  Less than a month later, on 17 April 2003, the PEB reconsidered her case as directed by the Physical Disability Agency and upon further review of medical documentation and rating guidance.  The PEB described her disability as post-concussive headaches following several head injuries, including one caused by a rock thrown by an artillery simulator, and that her condition had remained unresponsive to medical therapy, occurring on the average of once or twice a month, lasting several days and requiring bed rest and/or hospitalization.  The board recommended a 10 percent disability rating under VASRD                    code 8045-9304.  The board also recommended a 10 percent disability rating for her conversion disorder under VASRD code 9424.  The board found that the applicant was physically unfit and recommended that she be separated from the Army with a 20 percent disability rating.  The applicant nonconcurred and demanded a formal hearing.  

31.  On 29 April 2003 the applicant was seen by a clinical psychologist at Peterson Air Force Base in Colorado because the applicant was anxious and tearful.  He assessed her condition as PTSD (post traumatic stress disorder), histrionic features, and chronic headaches, indicating that MEB proceedings were underway.

32.  In a 14 May 2003 medical evaluation board addendum, the neurologist at the Air Force Academy stated that he had reviewed the applicant's board results, stating that he disagreed with the conclusion that her headaches were post-concussive.  He stated that he was at a loss as how the interpretation was reached given the majority of her clinical records had been written by him and he had not used that diagnosis.  He stated that the headaches were clearly migrainous and his narrative had clearly stated such.  He suggested overturning the recent decision and returning to the original PEB result.  

33.  On 15 May 2003 an attorney at Fort Carson queried a staff psychiatrist of the Air Force Academy concerning her [the psychiatrist] diagnosis as to the level of the applicant's social and industrial impairment, stating that the psychiatrist had indicated that her level of social and industrial impairment was definite.  He requested clarification, posing four questions to the psychiatrist.  The psychiatrist answered "Yes" to all the questions – the applicant did display some signs and symptoms of mental illness on examination; there was job instability due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, or mild memory loss; and she did have borderline social adjustment.  The psychiatrist also stated that the applicant would benefit from continued psychiatric intervention. 

34.  On 20 May 2003 a formal PEB affirmed the findings and the recommendation of the 17 April 2003 PEB, remarking that the applicant's testimony and health records clearly described a series of minor head injuries with marked onset of headaches which have become more prominent following each injury.  The PEB stated that the VASRD was clear under code 8045 that subjective complaints of headache symptomatic of brain trauma would be rated at 10 percent and no more in the absence of supporting organic findings.  The PEB stated that post-concussive headaches were known to have frequent migranious component.  The applicant did not concur, indicating that she submitted a statement of rebuttal.  That statement is not available to the Board.  

35.  On 17 June 2003 the PEB informed the applicant that her appeal was considered; however, the board adhered to the original findings and recommendations of the formal hearing.  She was informed that her entire case, including her rebuttal, was being forwarded to the Army Physical Disability Agency.  

36.  On 25 June 2003 the Army Physical Disability Agency informed her that her case was properly adjudicated and that the findings and recommendations of the PEB were supported by substantial evidence and were therefore affirmed.  She was informed that her case had been forwarded to the Physical Disability Branch for final disposition.

37.  Title 10, United States Code, chapter 61, provides disability retirement or separation for a member who is physically unfit to perform the duties of his office, rank, grade or rating because of disability incurred while entitled to basic pay.

38.  Title 10, United States Code, section 1201, provides for the physical disability retirement of a member who has at least 20 years of service or a disability rated at least 30 percent.
39.  Army Regulation 635-40 establishes the Army physical disability evaluation system and sets forth policies, responsibilities, and procedures that apply in determining whether a Soldier is unfit because of physical disability to reasonably perform the duties of his office, grade, rank, or rating.  It provides for medical evaluation boards, which are convened to document a Soldier’s medical status and duty limitations insofar as duty is affected by the Soldier’s status.  A decision is made as to the Soldier’s medical qualifications for retention based on the criteria in AR 40-501, chapter 3.  If the MEB determines the Soldier does not meet retention standards, the board will recommend referral of the Soldier to a PEB.

40.  Physical evaluation boards are established to evaluate all cases of physical disability equitability for the Soldier and the Army.  It is a fact finding board to investigate the nature, cause, degree of severity, and probable permanency of the disability of Soldiers who are referred to the board; to evaluate the physical condition of the Soldier against the physical requirements of the Soldier’s particular office, grade, rank or rating; to provide a full and fair hearing for the Soldier; and to make findings and recommendation to establish eligibility of a Soldier to be separated or retired because of physical disability.

41.  Department of Defense Instruction (DODI) 1332.38 provides for the DOD disability evaluation system and states in pertinent part that migraine conditions are cause for referral into the disability evaluation system, and that the number of incapacitating episodes (those that require the individual to stop the activity in which engaged and seek medical treatment) per week, month, or year should be noted and verified by a physician.  Estimation of the degree of social and industrial impairment incurred by the service member due to migraines should be included.   

42.  Congress established the VA Schedule for Rating Disabilities (VASRD) as the standard under which percentage rating decisions are to be made for disabled military personnel.  Percentage ratings in the VASRD represent the average loss in earning capacity resulting from diseases and injuries.  The ratings also represent the residual effects of these health impairments on civilian occupations.  

43.  Part 4, paragraph 4.1 of the VASRD states that the rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service.  The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such disease and injuries and their residual conditions in civil occupations.

44.  Diagnostic code numbers appearing opposite the listed ratable disabilities in the VASRD are arbitrary numbers for the purpose of showing the basis of the evaluation assigned and for statistical analysis by the VA, and extend from 5000 to a possible 9999.  When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be “built up.”  The first 2 digits will be selected from that part of the schedule most closely identifying the part, or system, of the body involved; the last 2 digits will be “99” for all unlisted conditions.  

45.  VASRD Code 8045, Brain disease due to trauma, is defined as follows:  "Purely neurological disabilities, such as hemiplegia, … facial nerve paralysis, etc., following trauma to the brain will be rated under the diagnostic codes specifically dealing with such disabilities, with citation of a hyphenated diagnostic code (e.g., 8045-8207).  Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under diagnostic code 9304.  This 10 percent rating will not be combined with any other rating for a disability due to brain trauma.  Ratings in excess of 10 percent for brain disease due to trauma under diagnostic code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma."

46.  VASRD Code 9304, Dementia associated with brain trauma, is classified in the VASRD as an organic mental disorder.

47.  VASRD Code 8100, Migraine, is classified as a disease in the VASRD.  Disability percentage ratings range from 50 percent – with very frequent prostrating and prolonged attacks productive of severe economic inadaptability; 30 percent – with characteristic prostrating attacks occurring on an average once a month over the last several months; 10 percent – with characteristic prostrating attacks averaging one in 2 months over the last several months; and 0 percent – with less frequent attacks.

48.  VASRD Code 9424, Conversion disorder, a somatoform disorder, with disability ratings ranging from 100 percent – total occupational and social impairment, to 0 percent – a diagnosed mental condition, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.  A 30 percent rating is indicative of a person with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).  A        10 percent rating indicates an individual with occupational and social impairment due to mild or transient symptoms with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.   
49.  In the processing of this case an advisory opinion was obtained from the Office of The Surgeon General.  The Surgeon General's neurology consultant stated that the applicant's medical records clearly documented a thorough evaluation over a longer period of time, and that there was no disagreement among the medical specialists over the etiology of her headaches.  She had migraines by all evidence.  That official stated that it was not reasonable to say she did not have migraine, given the uniform opinion of clinicians who examined her, the extensive evaluations and tests, and the clearly documented medical history.  The consultant stated that head trauma can be a precipitant of migraine and often is so, and that the existence of a past history of head trauma did not contradict, but rather supported, the diagnostic conclusions of all clinicians on her case.  The consultant stated that the PEB apparently misinterpreted an extensive medical case record when they modified their findings to post concussive headaches vice migraine headaches.  The Surgeon General recommended that the applicant's request for her diagnosis of migraine headaches be approved.   

50.  A copy of the advisory opinion was furnished the applicant.  She concurred with the opinion.  With her response she furnished a copy of a Department of Veterans Affairs (VA) rating decision showing that she was awarded a combined rating of 90 percent for service connected disabilities, to include a 30 percent rating for migraine headaches.

51.  Army Regulation 635-40 provides that an individual may be placed in a TDRL status for a maximum period of 5 years when it is determined that the individual is qualified for disability retirement under Title 10, United States Code, section 1201, but for the fact that his or her disability is not stable and the individual may recover and be fit for duty, or the degree of severity may increase or decrease so as to warrant a change in the disability rating.  A Soldier on the TDRL must undergo a period medical examination and PEB evaluation at least once every 18 months to decide whether a change has occurred in the disability for which the Soldier was temporarily retired.  Medical examiners will recommend removal of the Soldier’s name from the TDRL as soon as the Soldier’s condition permits.  A Soldier will be removed from the TDRL and separated with severance pay if the Soldier is unfit because of the disability from which the Soldier was placed on the TDRL; and either the disability has stabilized at less than 30 percent; or the disability, although not stabilized, has improved so as to be ratable at less than 30 percent. 
   
DISCUSSION AND CONCLUSIONS:

1.  The March 2003 PEB determined that she had migraine headaches which had progressed from post concussive headaches, and that her condition had remained unresponsive to treatments.  The PEB noted that her migraines occurred on an average of once or twice a month, lasting several days, and required bed rest or hospitalization.  However, less than one month later the PEB determined that her headaches were not migraines, but post concussive headaches following several head injuries, including one caused by a rock thrown by an artillery simulator; and in May 2003 a formal PEB affirmed that determination stating that she had post concussive headaches following several head injuries, and that concussive headaches are known to have frequent migraineous component.  The PEB indicated that her testimony and health records clearly described a series of minor headaches which became more prominent following each injury.  Consequently, the VASRD is clear – subjective complaints of headache symptomatic of brain trauma would be rated and          10 percent and no more in absence of supporting organic findings.   

2.  The applicant's headaches may have emanated from her head trauma as indicated by the May 2003 formal PEB; nonetheless, and regardless of the cause, the preponderance of evidence indicates that the applicant suffered from migraine headaches for approximately three years, and was seen, evaluated, and treated for such headaches.  Her nausea, vomiting, and sensitivity to light were symptoms of the migraine disease.  On numerous occasions, medical authorities, to include neurologists, determined that her headaches were migraines.  The medical evidence shows that she was placed on quarters and hospitalized on numerous occasions for her migraines – her commanding officer stating that her monthly migraines caused her to be hospitalized or on quarters for 5-10 days at a time.  In this respect, the Office of The Surgeon General is adamant that she has migraine headaches and recommends that the applicant be rated for migraine headaches. 

3.  In this respect, it would appear that the finding and recommendation of the     28 March 2003 PEB is correct, that is the applicant be placed on the TDRL with a 40 percent disability rating, 30 percent for migraine headaches, and 10 percent for conversion disorder, in that both conditions were unstable for adjudicative purposes.  

4.  Consequently, the applicant's records should be corrected by showing that:

a.  any action that resulted in discharging her with a 20 percent disability rating is null and void and of no force or effect; and

b.  she was physically unfit to perform the duties of her office, grade, rank or rating, that her physical condition was unstable for adjudicative purposes, and that she was placed on the TDRL on the date that she now was determined to be erroneously discharged, with a 40 percent disability rating, 30 percent for migraines under VASRD code 8100, and 10 percent for conversion disorder under VASRD code 9424.

BOARD VOTE:

___RW__  ___LE  __  ___MT__  GRANT PARTIAL RELIEF 

________  ________  ________  GRANT FORMAL HEARING

________  ________  ________  DENY APPLICATION

BOARD DETERMINATION/RECOMMENDATION:

1.  The Board determined that the evidence presented was sufficient to warrant a recommendation for partial relief.  As a result, the Board recommends that all Department of the Army records of the individual concerned be corrected by showing that:

	a.  any action that resulted in discharging her with a 20 percent disability rating is null and void and of no force or effect;

b.  she was physically unfit to perform the duties of her office, grade, rank or rating, that her physical condition was unstable for adjudicative purposes, and that she was placed on the TDRL on the date that she now was determined to be erroneously discharged, with a 40 percent disability rating, 30 percent for migraines under VASRD code 8100, and 10 percent for conversion disorder under VASRD code 9424.  

2.  The Board further determined that the evidence presented is insufficient to warrant the requested relief.  As a result, the Board recommends denial of so much of the application that pertains to permanently retiring the applicant with a 60 percent disability rating, 30 percent for migraine headaches and 30 percent for conversion disorder. 

		___ Raymond Wagner____
		        CHAIRPERSON

INDEX

CASE ID	AR2003096162	
SUFFIX		
RECON	YYYYMMDD	
DATE BOARDED	20040826	
TYPE OF DISCHARGE	(HD, GD, UOTHC, UD, BCD, DD, UNCHAR)	
DATE OF DISCHARGE	YYYYMMDD	
DISCHARGE AUTHORITY	AR . . . . .  	
DISCHARGE REASON		
BOARD DECISION	GRANT	
REVIEW AUTHORITY		
ISSUES         1.	108.00	
2.		
3.		
4.		
5.		
6.