RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300045
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20130529
SEPARATION DATE:  20040915

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty LT/O-3 (1110/Surface Warfare Officer) medically separated for recurrent vestibulopathy and migraine headaches.  The CI had a one year history of recurrent vertigo, variably associated with bilateral ear fullness, pressure and tinnitus (R>L) beginning around April 2003.  The CI reportedly suffered from headaches since age 12 that increased in frequency and severity in March 2003.  The recurrent vestibulopathy and migraine headaches could not be adequately rehabilitated to meet the physical requirements of her Rating or satisfy physical fitness standards.  She was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  Recurrent vestibulopathy and migraine headaches were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The PEB adjudicated recurrent vestibulopathy and migraine headaches as unfitting, rated 10% and 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals, and was medically separated.

CI CONTENTION:  “I was granted service-connection by the Department of Veterans Affairs for Meniere’s disease at 30%, residuals of hysterectomy at 30% and Migraine headaches at 10% effective to the day after my discharge from the US Navy.” 

SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting recurrent vestibulopathy and migraine headaches are addressed below.  The requested hysterectomy condition was not identified by the MEB/PEB, and thus is not within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Naval Records.

RATING COMPARISON:

Service IPEB – Dated 20040618	VA - (4 and 5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Vestibulopathy	6204	10%	Meniere’s Disease	6205	30%	20050125	
Migraine Headaches	8100	10%	Migraine Headaches	8100	10%	20050214	
No Additional MEB/PEB Entries	Other x 5	20050214	
Combined:  20%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20050214 and 20050524 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:

Recurrent Vestibulopathy.  The CI was treated for a right external ear infection on 28 March 2003.  She subsequently experienced onset of dizziness in April 2003 associated with ear pain, ringing in the ears, nausea and headache.  An audiogram on 20 May 2003 documented normal hearing.  Evaluation by otorhinolaryngology (ear nose and throat [ENT] specialist) on 20 May 2003 concluded with diagnosis of vertiginous migraine, however the CI experienced persistent lightheadedness and dizziness with weekly episodes of vertigo.  Videonystagmography performed on 16 June 2003 indicated “hyperactive bilateral peripheral vestibular system dysfunction.”  Follow up in the ENT clinic on 24 June 2003 noted intermittent vertigo, aural fullness (right greater than left), and tinnitus made worse by salt and caffeine.  The specialist noted the symptoms were clinically consistent with Meniere’s disease as well as vertiginous migraine.  A LIMDU board narrative summary (NARSUM) by the ENT physician dated 24 June 2003 listed the diagnosis as Meniere’s disease and recommended a period of LIMDU for treatment.  A neurology evaluation on 10 July 2003 noted a history of migraine headaches since age 12 that became significantly worse beginning approximately March 2003.  The neurologist noted the migraine headaches were associated with vertigo, tinnitus, and otalgia and that the CI reported always having had these ear symptoms with her headaches and had always been prone to motion sickness.  The diagnosis was classic migraine with migraine associated vertigo.  The neurologist indicated the vertiginous symptoms should improve with treatment for the migraine.  The 22 July 2003 ENT follow up appointment indicated non-specific diagnoses of recurrent vestibulopathy, otoneuralgia and “symptoms suggest migraine related associated vertigo.”  At the 28 July 2003 neurology follow up there was a “marked decrease in headache symptoms and dizziness.”  The neurologist suggested there may be vestibulopathy without migraine.  At a 24 November 2003 ENT follow up, the CI reported two relatively mild episodes during the preceding 6 months.  The physician noted the CI was doing well on Calan SR, a medication used for migraine prophylaxis.  The ENT physician noted a history of “Meniere’s disease” and migraine.  The CI was returned to full duty however she experienced recurrent symptoms and sought care in the ENT clinic on 8 April 2004.  The ENT physician noted bilateral ear fullness, pressure, tinnitus, right greater than left, fluctuating hearing loss in the right ear and episodic vertigo lasting up to an hour occurring four to five times per month.  The NARSUM noted report of worsening vertigo with increased frequency four to five times a month and lasting minutes to hours with associated headache, nausea, ear fullness, and tinnitus.  Physical exam, including gait and neurological was normal.  Physical examination tests of inner ear function and balance were normal.  The NARSUM noted that a magnetic resonance imaging scan of the posterior fossa, internal and auditory canal, and brain was normal.  The ENT physician noted the clinical presentation to be atypical for Meniere’s and that there was not a favorable response to treatments employed for the condition.  Diagnosis was recurrent vestibulopathy.  The 22 April 2004 commander’s statement indicated the CI was away from her work duties three to four hours per week for treatment, evaluation, and recuperation because of Meniere’s disease.  It was unpredictable and debilitating.  There were no further service treatment record (STR) entries in evidence for care of vertigo between April 2004 and separation on 15 September 2004.  At the VA ENT Compensation and Pension (C&P) exam on 25 January 2005, 4 months  after separation, the CI reported episodes of vertigo with the room spinning, with nausea and disequilibrium that occurred one to two times/month.  The last episode was January 2005, lasting for several seconds.  The vertigo would resolve with slight disequilibrium the rest of the day.  Fullness of the ears and tinnitus the night before the episodes preceded an episode early the next morning that occurred as she got out of bed.  She took medication which put her to sleep for two to three hours.  Examination of the external auditory canal and tympanic membranes was normal.  Audiogram was normal with 100% speech discrimination in both ears.  It was noted her hearing may fluctuate with episodes.  Recommendation was routine ENT follow up for Meniere’s disease.  At the C&P exam on 14 February 2005, 5 months post separation, CI indicated every 4 to 6 weeks, she had a ringing in either the right or less frequently the left ear, beginning with fullness in the ear and then pain.  There was vertigo when she awakened.  She took Antivert which put her to sleep for four to five hours.  She occasionally had mini attacks about twice/month that lasted a few seconds with no hearing loss.  The CI reported the vertigo was not associated with her migraine headaches and that they usually occurred separately.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the recurrent vestibulopathy condition 10% coded 6204, peripheral vestibular disorder, occasional dizziness.  The VA rated the condition 30% coded 6205, Meniere’s syndrome, hearing impairment with vertigo less than once a month.  The Board noted the final PEB diagnosis was recurrent vestibulopathy and not Meniere’s disease, however STRs indicated some diagnostic uncertainty regarding whether the CI’s vestibulopathy was Meniere’s disease or not.  There was no hearing impairment and there was a close association with the CI’s migraine headache condition.  All Board members agreed the vestibulopathy condition more nearly approximated the 30% rating under 6204 noting the symptoms were more severe than the occasional dizziness for the 10% rating.  Although the PEB diagnosis was not Meniere’s disease, the Board agreed a rating higher than 30% was not supported.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the recurrent vestibulopathy condition (6204).

Migraine Headaches.  CI has had occasional headaches with peri-menstrual exacerbation since age 12 and over the counter analgesics provided good relief until March 2003 when she noted a significant increase in headache frequency and severity with daily headaches of varying intensity.  Associated symptoms included phonophobia, nausea, vomiting, dizziness, bilateral tinnitus, and ear fullness and fatigue.  She was diagnosed with classic migraine headaches with associated vertigo and treated with various medications.  Imitrex and Excedrin controlled the headaches.  The neurology addendum to the NARSUM 2 June 2004 noted CI had more frequent and severe migraines during the previous hurricane season that had ended four months previously.  Daily headaches increased for two months with three to four severe headaches/month.  Diagnosis was migraine without aura with recommendation of no neurologic restrictions and continued medication.  The commander’s non-medical assessment indicated impairment due to Meniere’s but not migraine headache.  There were no service treatment record entries for treatment of severe headaches.  At the C&P Exam 14 February 2005, five months post separation, the CI reported two to three headaches per week with change in weather the number one trigger.  Sometimes there were spots in front of her eyes and then she developed paresthesias and prickling sensation in the forehead and all around her head.  Excedrin controlled headaches if taken early in the presentation.  If not treated early, the pain progresses to a squeezing sensation around her head and she developed nausea.  She would take Imitrex and lie down in a dark room a few hours.  She takes medications as needed but not for daily prophylaxis.  The exam, including gait and neurological was normal.  She was not working.  Diagnosis was peripheral vestibulopathy and tension headaches.  Both the PEB and VA rated the migraine headaches at 10%, coded 8100.  Although the VA C&P examination indicated the CI experienced prostrating attacks, none were documented in the service treatment records during the several months prior to separation.  The Board also noted the intertwined nature of the vertiginous symptoms and migraine symptoms with frequent co-occurrence already considered under the rating for the vestibulopathy condition above.  Although at the time of the C&P examination the CI reported the symptoms of the two conditions were distinct and occurred independently, this was not supported by the evidence of the service treatment records.  The Board therefore concluded the migraine headache condition more nearly approximated the 0% (zero) than the 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the migraine headache condition.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the recurrent vestibulopathy (Meniere’s) condition, the Board unanimously recommends a disability rating of 30%, coded 6204 IAW VASRD §4.87.  In the matter of the migraine headache condition, the Board unanimously recommends a disability rating of 0%, coded 8100 IAW VASRD §4.124a.  There were no other conditions within the Board’s scope of review for consideration.

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 her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Recurrent Vestibulopathy (Meniere’s) Disorder	6204	30%	
Migraine Headaches	8100	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130124, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
                                        COMMANDER, NAVY PERSONNEL COMMAND
	     	          		           	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
          (b) XXXXXXXXXXXXXXXXXX
          (c) PDBR ltr dtd 9 Aug 13 ICO XXXXXXXXXXXXXXXXXX
          (d) XXXXXXXXXXXXXXXXXX
          (e) XXXXXXXXXXXXXXXXXX 
                                               
1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (e).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

	a.  XXXXXXXXXXXXXXXXXX

	b.  XXXXXXXXXXXXXXXXXX, former USN, XXX XX XXXX:  Disability retirement with assignment to the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective 15 September 2004.

	c.  XXXXXXXXXXXXXXXXXX

d.  XXXXXXXXXXXXXXXXXX
	
3.  Please ensure all necessary actions are taken, included the recoupment of disability severance pay if warranted, to implement these decisions and that subject members are notified once those actions are completed.