RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX 			BRANCH OF SERVICE: AIR FORCE
CASE NUMBER:  PD0900425			BOARD DATE: 20101004
SEPARATION DATE: 20041207
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SUMMARY OF CASE:  This covered individual (CI) was an active duty Staff Sergeant/E-5 (Aircraft Armament Systems Journeyman, 2W151) medically separated from the Air Force in 2004 after four years of service.  The medical basis for the separation was Cluster Headaches. His did not respond adequately to treatment and he was unable to perform within his military occupational specialty. He was issued a permanent P-4 profile and underwent a Medical Evaluation Board (MEB). The CI was referred to the Physical Evaluation Board (PEB), determined unfit for continued military service, and separated at a 10% combined disability using the Veterans Affairs Schedule for Rating Disabilities (VASRD) and applicable Air Force and Department of Defense regulations.
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CI CONTENTION:  The CI states: ‘I was separated for Cluster Headaches in a 10% rating from the PEB. However, within 7 months of my separation, the VA raised my rating to 30%.  My condition did not worsen in the months between my separation and rating decision by the VA, and my condition remains unchanged to this day.  My headaches are so painful that I scream, cry, roll or lay on the floor, curl up into a ball, and bang my head against the floor or wall. Following an attack I am drained and spent, both physically and mentally.  The attacks come with daily frequency, with several attacks a day (a ‘cluster’), for approximately 6 to 8 weeks before the cycle ends.  I experience hundreds of attacks in a cycle, and a new cycle typically starts 6 months to 1 year later, meaning as much as 1/3 of a calendar year is spent suffering from these headaches.

The headaches severely limit my potential in the workforce.  First, they cut short my career in the Air Force.  The MEB/PEB occurred because I was found curled up under a bench in a backroom of my work center, where I had been beating my head against the concrete floor during an attack.  Also while on duty, I had a headache on the base’s flight line, where I curled up in an empty truck and beat my head and cried as jets taxied by.  Most of my headaches occur at night, fortunately, but it limits me to a few hours of sleep, which affects the next day’s work.  The compound effect of many weeks of sleep deprivation leaves me depressed, wasted and unable to interact normally with co-workers, friends and family. 

I went to school after the Air Force, where I had to skip classes and rely on friends to help keep up with the work because the headaches kept me awake for weeks or prevented me from leaving the house if the rare headache occurred during the day.  I have just found employment, and I am worried about my ability to maintain my job with condition, since I am lethargic, depressed, and slow-witted.  

Based on the severity, frequency, employment impact apparent at time of the PEB, they should have granted 50% under SRD 8100.’
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RATING COMPARISON:

Service IPEB 
20040902	VA (<1 Month Before & 5 Month After Separation)
All Effective 20041208	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cluster Headaches	8100-8199	10%	Cluster Headaches	8100	10%
then
30%	20041118

20050519	
	Not in DES	Tinnitus	6260	10%	20041118	
	Not in DES	Scars on Left Upper Arm with Residual Paresthesias status post Cyst Removal	7804	0%	20041118	
	Not in DES	Right Gamekeeper’s Thumb	5299-5228	0%	20041118	
TOTAL Combined:  10%	TOTAL Combined: 40% from 20041208	
	50% from 20090223 with:
10% 7804 Scars Left Upper Arm
10% 9434 Major Depressive Disorder associated with Tinnitus	
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ANALYSIS SUMMARY:

Cluster Headaches
The CI was first diagnosed with Cluster Headaches in 2001 when he was referred to an Italian neurologist.  He would have severe pain in the left temporal area accompanied by lacrimation and rhinorrhea.  At that time he had a normal head CT scan and a family history of Cluster Headaches was noted.  Other notes revealed the CI’s father also had Cluster Headaches.  The initial periodicity was not determined.  However, later history revealed the CI’s headaches occurred mostly at night and responded to abortive therapy.  He was medically cleared for deployment to Qatar with maintenance and abortive medications and was there from 20031203 to 20040304.  However, while deployed he began to experience the milder headaches he usually had prior to a cycle of Cluster Headaches and sought medical care and an Imitrex refill.  Multiple visits for medication refills between the time of the initial diagnosis and the deployment are documented in the service treatment record (STR).  Less than one month after he returned from this deployment he experienced a cycle of Cluster Headaches that did not respond to his usual medications and required multiple steroid injections along with 72 hours quarters.  This cycle of headaches lasted several weeks.  He was found by his co-workers curled up on the floor in a fetal position.  He was referred back to neurology, his medications were adjusted, and a Medical Evaluation Board (MEB) was started.  This cycle of headaches eventually resolved and no further headaches occurred prior to the evaluation for the MEB Narrative Summary (NARSUM).  The NARSUM references neurology and internal medicine consults but these are not available in the STR.  Both reportedly recommended avoidance of triggers such as stress, change in sleep cycles, alcohol, strong emotions, and excessive physical activity.  The NARSUM noted recurrent attacks could continue throughout the patient’s life but prolonged remissions were possible with appropriate medical therapy.  The NARSUM also noted the CI was not worldwide qualified.  In light of the history of recurrent Cluster Headaches with biannual episodes lasting from several days to several weeks, he would not be able to fulfill Air Force requirements.  An Informal PEB determined he was unfit for continued military service and rated his disability at 10%.  No VASRD code exists for Cluster Headaches and the condition was rated analogous to 8100 Migraine Headaches.

The VA Compensation and Pension (C&P) exam of 20041118 (less than one month prior to separation) noted the episodes of Cluster Headaches lasted between two and six weeks with the typical Cluster Headaches lasting anywhere from 15 minutes to all night.  Other milder headaches were present approximately 30 minutes before and 30 minutes after the Cluster Headache.  The CI would sometimes have as many as four or five headaches in one day.  The CI reported his pain was rated as 100 out of 10 during the Cluster Headaches.  He would lose awareness of his surroundings and beat his head against the wall or other hard objects.  The VA initially rated his Cluster Headaches at 10% but another C&P exam was done five months after separation and looking at both examinations, the VA determined the condition met the criteria for a 30% evaluation.  The second C&P examination was specific for neurological disorders whereas the first one was a general examination.  It clearly stated the headaches should be considered prostrating and that when the CI was cycling, he would have two headaches a night on average. 

A VA neurology consult of 20050722 (seven months after separation) stated the CI had been unemployed since leaving the Air Force.  He planned to go to Law School In August.  A primary care note of 20050914 stated he planned to attend Ohio Northern University law school in August.  Several VA treatment notes dated from June 2005 through September 2009 documented persistence of prostrating headaches with increasing frequency of cycles and only partial response to a variety of medications.  A VA progress note of 20070926 noted the CI was attending school.

Multiple service treatment notes as well as VA C&P examinations and the MEB NARSUM all document that on average prostrating Cluster Headaches occurred more than once per month but were not productive of severe economic inadaptability.  A military treatment note from July 2004 noted the CI had two 2-week Cluster Headache periods per year on average.  If the CI experienced only one per day during these episodes, that would be 28 headaches per year. That is more than one per month on average.  The frequency of cycles increased over time between 2001 and 2004 and the CI also began to have more headaches during the daytime. Initially most, if not all, of his headaches occurred at night and this caused less disruption of duty performance.

Other Conditions Not in the Disability Evaluation System (DES)
The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not considered by the DES in this case: Tinnitus, Scars on Left Upper Arm with Residual Paresthesias status post Cyst Removal, Right Gamekeeper’s Thumb, and Major Depressive Disorder.
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BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  After careful consideration of all available evidence the Board unanimously determined that the CI’s Cluster Headaches are most appropriately rated at 30%.  As there is no VASRD code specific for Cluster Headaches this condition is rated analogous to Migraine Headaches 8100.  Under this code, characteristic prostrating attacks occurring on an average of once a month over the last several months are evaluated with a 30% rating.  Although the CI’s headaches occurred in cycles with intervening Cluster Headache-free periods, on average, his headaches occurred at least once a month and probably even more frequently.  By their very nature, Cluster Headaches are prostrating and the CI was noted to be lying on the ground in severe pain by his co-workers during one witnessed attack.  After separation from service, the CI was attending school and while there is no information about his performance at school, there is also no evidence of severe economic inadaptability and therefore a 50% rating is not warranted.

The other conditions rated by the VA (Tinnitus, Scars on Left Upper Arm with Residual Paresthesias status post Cyst Removal, Right Gamekeeper’s Thumb, and Major Depressive Disorder) were not mentioned in the Disability Evaluation System package and are therefore outside the scope of the Board.  The CI retains the right to request his service Board of Corrections for Military Records (BCMR) consider adding these conditions as unfitting.  
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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows and that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation.

UNFITTING CONDITION	VASRD CODE	RATING	
Cluster Headaches	8199-8100	30%	
COMBINED	30%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090629, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

                             	 

SAF/MRB
1535 Command Drive, Suite E-302
Andrews AFB, MD  20762-7002

	Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2009-00425.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Administration Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

	As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at 1-800-531-7502 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.  

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN

PDBR PD-2009-00425

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Section 1554, Title 10, United States Code (122 Stat. 466) and Section 1552, Title 10, United States Code (70A Stat. 116) it is directed that:

	The pertinent military records of the Department of the Air Force relating to XXXX, are corrected to show that:

		a.  The diagnosis in his finding of unfitness was Cluster Headaches, VASRD Code 8199-8100, rated at 30% rather than 10%.

		b.  On 7 December 2004, he declined coverage under the Survivor Benefit Plan (SBP).

		c.  He was not discharged on 7 December 2004; rather, on that date he was relieved from active duty and on 8 December 2004 his name was placed on the Permanent Disability Retired List.