RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300647
BRANCH OF SERVICE:  Army	BOARD DATE:  20140520
SEPARATION DATE:  20061016

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (92Y/Supply Sergeant) medically separated for chronic daily headaches compounded by a mood disorder.  The migraines and mood disorder could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P4S3 profile and referred for a Medical Evaluation Board (MEB).  The headaches and mood disorder, characterized as “chronic recurring severe headaches with migrainous component and chronic daily headache” and “mood disorder” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded posttraumatic stress disorder (PTSD) and three other conditions for PEB adjudication.  The Informal PEB adjudicated “chronic daily headaches…compounded by a mood disorder due to a general medical condition” as unfitting, rated 0%, with application Department of Defense Instruction (DoDI) 1332.39.  PTSD and the other remaining conditions were determined to be not unfitting, and were not rated.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her application.

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 applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that she may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20060925	VA - (7 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Daily Headaches…compounded by a Mood Disorder	8100	0%	Migraine Headaches	8100	30%	20070509	
			Panic Disorder and Depressive Disorder	9412	30%	20070509 	
PTSD	Not Unfitting	PTSD	Not Service Connected	20070509	
Other x 3 (Not in Scope)	Other x 11		
Rating: 0%	Combined:  70%	
Derived from VA Rating Decision (VARD) dated 20070712 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

The PEB combined the headache and mood disorder conditions under a single disability rating, coded 8100 (migraine headaches).  Although this approach may comply with service policy, the Board must apply separate codes and ratings in its recommendations, if compensable ratings for each condition are achieved IAW the VASRD.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition is reasonably justified as separately unfitting.  The Board's initial charge in this case was therefore directed at determining if the PEB's approach of combining conditions under a single rating was justified in lieu of separate ratings.  If it is judged that one or more of the combined conditions satisfies the unfitting stipulation from above, separate ratings IAW the VASRD are recommend; although, the Board may not recommend a lower combined rating than that achieved by the PEB’s approach.

Chronic Daily Headaches.  At the neurology evaluation on 6 September 2005, the CI reported a 2-year history of headache problems.  Headaches had increased in frequency and could be brought on by stress or exercise.  She endorsed five headache days per week and reported missing 5 days of work in the prior month due to headaches.  A primary care clinic entry on 20 October 2005 (a year prior to separation) for care of an acute headache noted a headache frequency of once per week.

During a deployment to Iraq between November 2005 and March 2006, the CI was seen multiple times for worsening headaches.  At a visit for acute headache treatment on 18 January 2006, migraine attack frequency was reported to be “every couple of weeks.”  She was given an injection of two medications she stated were helpful in the past (Toradol and Phenergan).  At a visit on 19 February 2006 (8 months prior to separation), she reported that during the previous 6 months she experienced 2-3 migraines per week.  At a follow-up visit on 27 February 2006, the examiner clarified that in addition to the migraine headaches; the CI was now reporting a 2-3 year history of daily headaches that were of lesser severity and not associated with the nausea and vomiting she experienced with migraines.  During a follow-up on 1 March 2006, the CI stated she was using abortive agents once or twice per week.  Clinical documentation while deployed consistently reported the effectiveness of Toradol and Phenergan injections in aborting acute headaches.  Due to the frequency of her migraine headaches and unresponsiveness to prophylactic treatment, the CI was medically evacuated from theater in March 2006.  The CI informed aeromedical evacuation personnel on 6 March 2006 that two prophylactic medications she was taking (Elavil and Atenolol) “will not stop the pain and will only prevent a migraine.”

At a follow-up on 31 March 2006 (6.5 months prior to separation) with the same neurologist who saw her prior to deployment, it was noted that the character of the severe migraine headaches had not changed, but she now stated that she had no headache free days during the past 3 years.  Her headaches began suddenly, without much warning.  The CI was electively admitted to the hospital in April 2006 for an intravenous (IV) migraine headache drug protocol in an attempt to break the daily cycle of daily headaches that was refractory to multiple medications.  After 72 hours of continuous IV medication, there was no improvement in her headache.  She declined one medication (Phenergan) which had previously been helpful due to sedative side effects.  At times that her headache severity was reported to be 9 out of 10 (on a 0-10 scale), she appeared to be in “no apparent distress, watching TV, and conversing normally.”  The neurologist stated:  “I strongly suspect her headaches are not as severe as she reports...” and “I doubt I will be able to provide any treatment that she states will be useful for headache control.”

The commander’s statement on 16 June 2006 (4 months prior to separation) noted that the migraine headaches severely limited her ability to perform her job and headache medications caused sleepiness, nausea or vomiting.  At the narrative summary (NARSUM) exam on 9 August 2006 (2 months prior to separation) the CI reported that she was never pain free, experiencing pain at least 4-5 out of 10 constantly.  She suffered very debilitating headaches twice per week, which were 10 out of 10 in severity.  Her usual duties, such as looking at computer screens for prolonged periods, moving heavy items or wearing customary protective equipment exacerbated her headaches.  A NARSUM update on 14 September 2006 addressed the issue of frequency of prostrating headaches, as defined by the need to seek immediate medical care.  Prostrating headache frequency was thought to be three per week when she first saw neurology a year prior.  She had not gone to work during the past 3 months, but reported taking abortive medication which would cause her to sleep 3 days per week.  The CI noted that “for the most part she can function on these medications.”  The more severe headaches were usually 10-14 hours in duration.  Twice per month she experienced headaches that lasted 2-3 days and kept her in bed.  In a commander’s statement update on 19 September 2006, it was stated that since her return from deployment, the CI had not worked a full duty day due to profile restrictions.  She remained at home and called in each morning to her Platoon Sergeant.

At the VA Compensation and Pension (C&P) exam on 9 May 2007 (7 months after separation), the CI reported being employed full-time since February 2007.  She had so far missed 6 days of work due to her headaches.  She indicated her migraine headaches first started in 1995, but in 2005 “the intensity exploded. She would have a migraine every other day.”  She reported that none of the medications she had been given in the service helped her with her migraine symptoms and she was currently taking no medications for headaches.

The Board first considered if chronic daily headaches, having been de-coupled from the combined PEB adjudication, remained unfitting as established above.  The headache condition was profiled and was considered to fall below retention standards by the NARSUM examiner and the MEB.  The commander’s statement indicated the degree to which the headache condition interfered with performance of duties.  Members agreed that the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to perform her MOS and, accordingly a separate rating is recommended.

The PEB used the 8100 code, and cited “absence of prostration” as the rationale for a 0% rating.  The PEB’s definition of prostration was “the need to drop what she is doing and seek medical attention.”  The VA assigned a 30% rating for “characteristic prostrating attacks averaging one in 2 months over last several months.”  When rating headaches under the diagnostic code 8100, VA guidance uses the clear English definition of prostrating.  The standard dictionary definition of “prostration” is “utter physical exhaustion or helplessness,” and does not indicate that seeking medical attention is required.  The Board noted that the headache frequency as reported by several examiners was quite variable and conflicting and that there was contradictory information regarding abortive and prophylactic medication effectiveness.  In debating the frequency of prostrating attacks during the period leading up to separation, Board members debated whether a severe headache correlated with prostration since she appeared quite comfortable to the neurologist while complaining of a severe headache.  It was also noted that (per the NARSUM examiner) she took abortive medication for the more severe headaches 3 days per week, but could function on these medications; but twice per month a headache could last 2-3 days and keep her in bed.  The Board also considered (after separation) the willingness to allow all headache medication prescriptions to lapse in the presence of presumed prostrating events; and the possible correlation between missed work at her new job as reported to the C&P examiner and prostrating events.  The Board ultimately agreed that the described clinical picture most closely approximated the 10% criteria (“characteristic prostrating attacks averaging one in 2 months over the last several months”).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic daily headaches condition.

Mood Disorder Due to General Medical and PTSD Conditions.  During clinic visits for her migraine headaches in February 2006 (while deployed, 8 months prior to separation), the CI denied any symptoms of depression or of having “any excessive stressors.”  On the post-deployment assessment on 22 March 2006 (6 months prior to separation) the CI denied frightening or horrible experiences that resulted in nightmares, avoidance or hypervigilance; denied seeing wounded, killed or dead and did not feel she was in great danger of being killed while deployed.  She endorsed “feeling down, depressed or hopeless.”

The earliest evidence of MH care was on 22 March 2006 when she was referred for indications of hypervigilance, depression and sleep problems and to assist in pain management; an antidepressant medication was prescribed at that time.  At a psychiatry visit on 2 May 2006, the applicant reported an increase in anxiety and depression due to fears that the migraines would not improve.  No other MH history was provided.  Diagnoses of acute PTSD and adjustment disorder were given and an antianxiety medication was prescribed.  A follow-up note on 26 May 2006 written by the same MH provider, indicated the purpose of the visit was for “PTSD, deployment related.”  Aside from the pain of “almost constant” migraines, she described continued tearfulness and irritability, but denied nightmares.  Sleep disturbance was considered to be due to pain.  The CI thought that her depression was due to the negative impact her migraines had on socializing with others.  She had “numerous plans for the future” with her husband.  An additional medication for mood was started.  A commander’s statement on 16 June 2006 (4 months prior to separation) described that the migraine headaches significantly interfered with her ability to perform her job.  The only mental impairment noted was due to headache medication side effect (i.e. sleepiness).

The psychology addendum examiner on 26 July 2006 (2.5 months prior to separation) noted that as the headache condition worsened, the CI felt more depressed.  She complained of decreased appetite, lack of enjoyment, no energy, anxiety, sleeping difficulty and irritability.  Although she complained of social withdrawal to the point that she would leave her home only for appointments, she acknowledged fishing with her husband and interacting with her religious group.  The examiner did not review any history of PTSD, or the occurrence or timing of any prior MH history or treatment and did not describe how MH symptoms impacted occupational functioning.  A brief mental status exam (MSE) was unremarkable except for variable affect related to “the topic being discussed.”  The Axis I diagnosis was “mood disorder (depression and anxiety) due to general medical condition.”  An assigned Global Assessment of Functioning (GAF) was 45 (connoting serious symptoms or impairment).  The medical NARSUM examiner on 9 August 2006 reported that the CI was doing “a little bit better” on the antidepressant medication.  The examiner noted the MH clinic entries with a diagnosis of PTSD.  The CI stated that “she has times of reliving moments in combat.”  A diagnosis of mood disorder was noted to fail retention standards; and a diagnosis of PTSD was not deemed to fall below retention standards.

At the VA psychiatric C&P exam on 9 May 2007 (7 months after separation) the CI indicated that she had discontinued the antidepressant medication.  Her past history included being sexually abused and raped when she was younger than 10 years of age and when she was 13.  Per this examiner, her diagnosis of PTSD stemmed from these childhood events.  She denied significant trauma during the past year.  Nightmares no longer occurred on a regular basis, but she did complain of panic attacks once per week prompted by fear of a migraine onset.  Her depression reportedly began while deployed to Iraq (November 2005 – March 2006) and became quite severe.  Currently, she still had “some of the residual symptoms of her significant episode of depression” which included difficulty with motivation, social isolation, difficulty with concentration and memory and tearfulness.  Her first marriage ended in divorce, but she was engaged to be married in 5 months.  She was working on a Master’s degree, and held a job as a data entry clerk for a DoD contractor.  She had “no complaints” about her current job.  MSE was remarkable for a mildly dysphoric mood and restricted affect.  Mild memory and concentration problems were present.  The Axis I diagnoses were PTSD (“chronic and mild”) secondary to childhood abuse and panic disorder and depressive disorder due to recurring migraines.  A GAF was 60 (moderate symptoms or impairment).  The medical C&P examiner noted that the CI had been employed full time since 28 February 2007 and that she had missed 8 days of work for headaches and bronchitis.

The Board considered the appropriateness of changes in the MH diagnoses, PEB fitness determination; and if unfitting, whether the provisions of VASRD §4.129 were applicable, and a disability rating recommendation in accordance with VASRD §4.130.  The Board reviewed the records for evidence of inappropriate changes in diagnosis of the MH condition during processing through the military Disability Evaluation System.  The evidence of the available records shows that diagnoses of mood disorder and PTSD were rendered.  The Board therefore determined that the MH diagnosis was not changed to the applicant’s possible disadvantage in the disability evaluation.  This applicant therefore did not meet the inclusion criteria in the Terms of Reference of the MH Review Project.

The Board first considered if mood disorder due to general medical condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  Members agreed that, based on the above evidence, there was a questionable basis for arguing that it was separately unfitting.  The well-established principle for fitness determinations is that they are performance-based.  Although the psychology addendum examiner considered the condition to fall below retention standards, the report did not specify how mental symptoms (separate from migraine headaches) affected job performance and the detailed commander’s statement only implicated the migraine headaches as an impediment to job performance.   The Board could not find evidence in the service treatment record that documented any significant interference of mood disorder or any MH symptoms (to include PTSD), with the performance of duties at the time of separation.  After separation, the C&P examiner confirmed that occupational functioning in her new position was not impaired on the basis of the MH symptoms.  After due deliberation, members agreed the evidence does not support a conclusion that the functional impairment from mood disorder, or from PTSD, was integral to the CI’s inability to perform her MOS and, accordingly cannot recommend a separate rating for them.  The Board concluded therefore that the mood disorder condition could not be recommended for additional disability rating.  Furthermore, after due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the PTSD 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.  As discussed above, PEB reliance on DoDI 1332.39 for rating chronic daily headaches was operant in this case and the condition was adjudicated independently of that instruction by the Board.  In the matter of the chronic daily headaches compounded by a mood disorder due to general medical condition, the Board unanimously recommends that it be adjudicated as two separate conditions.  In the matter of the chronic daily headaches condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 10%, coded 8100 IAW VASRD §4.124a.  In the matter of the mood disorder due to general medical condition, the Board unanimously agrees that it cannot recommend a finding of unfit for additional disability rating.  In the matter of the contended PTSD condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Headaches	8100	10%	
Mood Disorder Due to General Medical Condition	Not Unfitting	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130514, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAMR-RB								
MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXX, AR20140014468 (PD201300647)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl