RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-00869
BRANCH OF SERVICE:  Army	BOARD DATE:  20140328
DATE OF PLACEMENT ON TDRL:  20011114
Date of Permanent SEPARATION:  20060310

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an active duty (AM2/Aircraft Mechanic) medically separated for a migraine headache condition.  He had a long history of intractable headaches with a hospitalization for that complaint in 1999.  Despite medication the headache condition could not be adequately rehabilitated to meet the requirements of his Rating, so he was referred for a Medical Evaluation Board (MEB).  The headache condition, characterized as “migraine, unspecified and benign intracranial hypertension” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E, with no other conditions submitted by the MEB.  The PEB adjudicated “migraneous headache” as unfitting (Category I), rated 30%, and “benign intracranial hypertension” as not unfitting (Category III), with likely application of the VA Schedule for Rating Disabilities (VASRD).  The CI was placed on the Temporary Disability Retired List (TDRL) effective on 14 November 2001.  The CI appealed and requested a Formal PEB, requesting to remain on active duty.  There was no FPEB performed and the applicant remained on the TDRL until 10 Mar 2006.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application, but did include a lengthy statement, with the concern being basically that the VA would not pay disability compensation until severance pay from the military was reimbursed.  The CI also made a point regarding the impact his disability and other medical conditions (a back condition) continue to have on his work and quality of life.

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 rating for the unfitting migraine headache condition is addressed below; no additional conditions are 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.  The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him, but must emphasize the Disability Evaluation System has neither the role nor the authority to compensate members for subsequent severity or complications of conditions that resulted in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board also acknowledges the challenge the CI reports regarding repayment of military disability severance pay, but must emphasize it has no role or authority to address that concern.

RATING COMPARISON:

Final Service PEB - 20060310	VA (12 Mo. Post -Adjudication Date*) - Effective 20011113	
On TDRL - 2001114	Code	Rating	Condition	Code	Rating	Exam	
Condition		TDRL	Sep.					
Migraineous Headache	8199-8100	30%	10%	Postencephalitic, Chronic Daily Headache Condition	8199-8100	50%	20021124	
Benign Intracranial Hypertension	Category III (Not Unfit)	No VA Rating		
No Additional MEB/PEB Entries.	Other x 1		
Combined:  30% → 10%	Combined: 50%	
*Reflects VA rating exam proximate to placement on TDRL

ANALYSIS SUMMARY:

Migraine Headache Condition.  Available treatment records indicate the CI began having headaches accompanied by fever in November 1999.  The narrative summary (NARSUM) noted the CI reported his daughter had a fever and headache; 2 days later, he had similar symptoms.  He developed disorientation, vertigo, aphasia, nightmares and photophobia with a sudden onset of bilateral frontal and temporal headaches aggravated by position, accompanied by nausea and a temperature of 100 degrees.  Lumbar puncture recorded elevated intracranial pressure (ICP) but no infectious source was identified.  The CI’s brain scan was negative.  The CI was admitted to the hospital, viral meningitis was assessed and he was discharged with pain medication.  A magnetic resonance imaging performed on 11 November 1999 was negative for evidence of a mass, edema, inflammatory process or vascular lesion.  A neurology consult dated 5 January 2000 noted the CI was hospitalized for 5-6 days with the diagnosis of viral encephalitis, which was treated with antibiotics.  He continued to have headaches, described as sharp pain and pressure which usually lasted for minutes.  The CI also had severe headaches that lasted for hours, at times accompanied by dizziness, blurred vision and nausea.  Vicodin had been prescribed.  On physical examination, gait was normal, he could heel and toe walk and sensation and motor exams were normal.  Pupils were equal and reactive to light and accommodation and there was no evidence of ptosis (drooping of the eyelid).  Extraocular movements were full, disc flat and visual fields were full.  The diagnosis was aseptic meningitis, resolving, and post-traumatic headaches.  The neurologist opined the CI’s condition would resolve completely so follow-up consultation was not recommended.  A week later, the CI presented to medical clinic with report of a headache with absence of visual disturbance and no nausea.  He was diagnosed with chronic headache syndrome and prescribed antihypertensive prophylaxis and abortive medication.  At a neurology consult exam on 26 October 2000, the CI reported his headaches worsened after tapering of nortriptyline.  They became more intense and interfered with his desire to participate in activities.  He was able to continue to work regularly despite the headaches.  The neurologist noted the previous lumbar punctures recorded ICP but attempts to decrease the pressure did not provide relief.  Several medication attempts with narcotics, non-steroidal anti-inflammatory drugs, antidepressants, antihypertensive medications (all aimed at preventing and relieving headaches) had been unsuccessful.  On physical examination the CI was in no acute distress, his motor, sensory and coordination examinations were normal, cranial nerves were intact and reflexes were normal.  Visual fields were also intact.  The CI was prescribed treatment with a combination of a long-acting preparation of an anti-hypertensive medication for prophylaxis and a narcotic agent for acute headache management.  A referral to neuro-opthalmology was recommended for further evaluation of increased ICP.

The CI underwent consultation with a pain clinic in February 2001.  He described the headaches as intermittent, occurring daily, lasting from an hour to several hours.  Headaches were exacerbated by heat and noise but relieved by sleep, rest and medication.  He was able to get a good night’s sleep and the pain did not interrupt his sleep.  His medications at the time, Vicodin and Neurontin, were helpful.  The physician recommended a trial of biofeedback and tapering of Vicodin to avoid rebound headache phenomenon, and noted infusion therapy might be necessary.  There was no profile or commander’s statement available in evidence.

On 4 June 2001, the NARSUM examiner noted a history of intractable headaches, status post a brain infectious process or pseudo-tumor cerebri syndrome.  After a month of persisting headaches several different trials of medication were attempted with little benefit.  In February 2001, the CI underwent a trial of lidocaine infusion therapy.  He responded well, but attempts to switch to the oral preparation were unsuccessful.  In March 2001, his medication was changed over to methadone, which allowed tapering of the Vicodin.  At the time of the NARSUM exam the CI reported the methadone had improved the nausea but did little to resolve the headaches and he continued to have difficulties carrying out normal duties.  Neurological examination was completely normal.  The physician characterized his diagnosis as: “The diagnosis does not fit any one particular syndrome perfectly but ranges between pseudotumor cerebri versus chronic migrainous headache, post encephalitis.  Because of the patient’s history of addictive behavior the persistent reliance on the narcotics…he has been very refractory to all alternate forms of management…it is felt that his headaches have a meningeal origin…in the present state the member is unfit and his medications present risk for operating any type of machinery.”  The CI was placed on the TDRL.

At the Compensation and Pension examination on 24 November 2002 (approximately 15 months after TDRL placement), the examiner noted the history of increased ICP without history of edema or visual impairment.  The CI reported no benefits from Lidocaine infusion therapy and noted he then had headaches described as being located generally behind the right side of the left eye, at times associated with slight nausea.  His headaches were reportedly occurring daily.  Again, there was no visual disturbance or photophobia accompanying the headaches.  Physical examination was normal, and the neurologist assessed post-encephalitic chronic daily headache.  On 15 September 2003, the CI underwent his first TDRL examination.  He noted he would experience a headache if he did not take his pain medication, though Oxycontin was effective in relieving the headaches.  His had daily headaches at the time, reported as sharp, sometimes throbbing; nothing seemed to make it worse, and only his pain medication made it better.  His headaches were sometimes accompanied by slight nausea.  Physical examination was completely normal.  The CI was maintained on the TDRL.  At the second TDRL examination on 29 November 2004, the CI reported continued benefit from his medication and noted he did not have any significant headache if he took his medication.  He had not lost time from work due to headaches, and was working fulltime as a chemical dependency counselor.  Physical examination was completely normal.  The neurologist diagnosed probable narcotic medication overuse headache and recommended tapering off of narcotics.  At the TDRL psychiatric examination on 27 February 2006, the CI reported he had tried a number of medications to control his headaches, including Methadone and Oxycontin.  He had been recently prescribed preventive medication which was of no benefit.  The CI reported he had not worked due to his headaches, but was attending school part-time, at times having to leave due to headaches.  He only employed abortive agents for his headaches, usually Vicodin, consuming around 60 tablets a month (usual dosage of Vicodin is 1-2 every 4-6 hours, not to exceed 8 daily, or ~240 per month).  The CI reported he had headaches more days than not, but did not address frequency.  He reported no history of vision changes with headaches and he usually did not have light or sound sensitivity, nausea or vomiting.  Physical examination was normal.  The neurologist diagnosed chronic daily headaches, and opined the headaches were disabling and limited his daily activities.

The Board directs attention to its rating recommendation based on the above evidence.  At TDRL entry, the PEB adjudicated the CI’s headache condition at 30% coded 8199-8100 (migraine).  The Board deliberated whether the condition met the 30% or the 50% rating using code 8100 at the time of TDRL entry.  The 30% rating requires once monthly over several months of prostrating headache attacks, while the higher rating of 50% requires “completely prostrating and prolonged attacks productive of severe economic inadaptability.”  The Board concluded the available evidence indicated the headache condition most nearly met the 30% rating criteria of 8100.  The NARSUM noted the CI’s headache had improved on medication; he was unable to carry out his normal duties (aircraft mechanic), but was successfully working in an office environment.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in rating for the migraine headache condition at TDRL entry.

At the conclusion of TDRL, the PEB (convened on 10 March 2006) adjudicated the headache condition as unfitting, rated 8199-8100 (analogous to migraine headaches) at 10% disability.  The 2004 TDRL exam recorded absence of clinically significant headaches with medication adherence.  The CI was working fulltime and reported no loss of work due to headaches.  The Board noted attacks decreased over time both in frequency and intensity and were reported by the CI to be controlled by medication.  There was no evidence of incapacitating episodes or emergency room visits.  The 2006 TDRL exit NARSUM recorded the CI was not working, but was attending school part-time.  He continued to report headaches that were opined to be somewhat refractory to medication.  It was noted that he only employed abortive therapy in the form of Vicodin, and took no medication to prevent headaches.  The Board discussed the reported use of Vicodin at 60 tablets per month as needed, to determine whether (if taken in maximum dose of 8 per headache episode) this would be equivalent to less than 8 days a month or one daily recommended dose.  At the time of TDRL separation, Board members agreed the 10% rating criteria were met, so the Board then considered whether a 30% or 50% rating could be supported by the evidence.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority agreed that sufficient cause existed to recommend a change in the PEB adjudication for the migraine headache condition at permanent separation.

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 migraine headache condition, the Board, by a majority vote, recommends a disability rating of 30%, coded 8999-8100 IAW VASRD §4.124a.  The single voter for dissent did not elect to submit a minority opinion.  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 his prior medical separation::

UNFITTING CONDITION	VASRD CODE	RATING	
		PERMANENT	
Migraineous Headache	8199-8100	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130607, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, COUNCIL OF REVIEW BOARDS

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION
XXXXXXXXXXXXXXXXXX, FORMER USN

Ref:   (a) DoDI 6040.44
(b) PDBR ltr dtd 14 Jul 14

I have reviewed subject case pursuant to reference (a) and do not concur with the recommendation of the Physical Disability Board of Review as set forth in reference (b). I found insufficient evidence to warrant a permanent increase in the 10% disability rating previously awarded by the Physical Evaluation Board in 2006.  That PEB's rating was supported by the record before them and was neither arbitrary nor capricious.

Please take appropriate administrative action in accordance with my decision.