RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00688
BRANCH OF SERVICE:  COAST GUARD 	SEPARATION DATE:  20070409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Yeoman, medically separated for migraine headaches; with a disability rating of 0%.  

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  The applicants complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

SERVICE PEB - 20070212	VARD - 20070822	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine: with Less Frequent Attacks	8100	0%	Migraine Headaches	8100	30%	20070802	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Migraine Headaches.  According to the service treatment records (STR) and the narrative summary (NARSUM) the CI was diagnosed with migraine headaches in 2004 and referred to a neurologist for care in 2005.  Imaging of the brain, including computed tomography scans and magnetic resonance arthrogram, was negative for aneurysm or tumor and the diagnosis of migraine headaches was confirmed.  Various medication regimes were tried without adequate control of the headaches.  At a neurology consult on 20 April 2006, the CI was prescribed a daily preventive migraine medication (Topomax), in addition to two medications to abort and treat any breakthrough headaches.  At a primary care (PC) visit 15 June 2006, the CI reported these medications were effective at controlling the headaches and at a neurology follow-up visit on 22 June 2006, the CI reported three headaches per month that responded to treatment medications.  At a PC visit 7 September 2006, the CI reported that his headaches were increasing in frequency and were not responding to medications and that the neurologist did not think he was fit for full duty/sea duty status.  The neurologist wrote a letter on behalf of the CI dated 15 September 2006, excerpted here, which indicated the headaches were controlled as long as the CI used his prescribed medications.

XXXX has migraine headaches without aura (346.10), which are under good control if he takes Maxalt 10 mg at the onset.  Without the medication the headaches could last up to a day or at least 6-8 hours during which I would suspect there would be some interference with functioning aboard ship.  As you aware, migraines are a condition that would be lasting for many years with XXXX.  However, with his present medications he is able to abort the headaches in about 20-30 minutes without side effects.  

A follow-up PC visit on 5 October 2006 noted that despite maximal treatment, the CI’s migraine headache condition continued to interfere with his work.  The CI was given a profile with limitations of no boat or sea duty or pepper spray exercises and he was referred for a Medical Evaluation Board (MEB).  The treatment records fell silent with regard to care for headaches between October 2006 and the date of separation, 6 months later.  Review of treatment visits in record reveals six encounters for care for the headaches condition in the 12 months before separation and none were for acute headaches.  

The commander’s statement dated 15 December 2006 concurred with the MEB and indicated the CI’s medical condition “prevents him from being a fully functioning yeoman.”  

The MEB NARSUM exam performed 2 November 2006, 5 months before separation noted that the CI’s migraine headaches condition was stable on medications, but he continued with seven to eight headaches per month that were “disabling him from performing his duties.”  There was no physical examination documented at the MEB NARSUM examination.

At the VA Compensation and Pension (C&P) examination dated 2 August 2007, 4 months after separation, the CI reported 4-8 headaches per month that lasted for 16 hours, associated with neck and right eye pain, nausea, blurred vision, dizziness, and sensitivity to light and sound.  He reported use of different preventive medications than he had been taking during active duty, with the same abortive medication (a remote C&P examination indicated the preventive medication had been changed in an attempt to decrease headaches frequency even further).  The CI was employed as a Human Resources supervisor and reported that during the headaches he could do some household chores, but could not go to work.  A complete examination, including neurological examination, was normal.

At a VA primary care outpatient visit on 6 December 2007, the CI reported he had four to eight migraines per month, controlled with the same preventive and abortive medication regime noted at the initial C&P exam.  

The Board directed its attention to its rating recommendation based on the above evidence.  
The PEB and VA both used the migraine HA condition 8100 code (Migraines).  The PEB rated the HA condition 0%, citing “with less frequent attacks” and the VA rated it 30%, citing “frequent attacks, without evidence of completely prostrating, and prolonged attacks productive of severe economic inadaptability.”  

Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months”.  The VASRD does not further define prostrating attacks however commonly accepted definitions include “utter physical exhaustion or helplessness” (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or “extreme exhaustion or powerlessness” (Dorland's Illustrated Medical Dictionary).  All Members agreed to this general definition of “prostrating” headache attacks for its ratings deliberations.  The Board noted that the VA granted a higher rating than that adjudicated by the PEB based on the CI’s self-report of the frequency and duration of headaches at the time of the post-separation C&P examination.  The Board considered that the notes in the STR indicated that the CI experienced much improved control of his headaches with new medication prescribed by the neurologist in April 2006, with frequent headaches, however with good response to medication in a half hour or less.  At a PC visit in September 2006, the CI reported that his headaches were “uncontrolled” despite medications.  However, this was not corroborated by the neurology letter a week later.  At the C&P examination, the Board noted that the effective medication regimen had been altered (preventive medication had been changed), perhaps leading to worsened control.  However, at a VA outpatient treatment visit, 4 months later, the CI reported his headaches were controlled with the same medications and in the 12 months post-separation there were no urgent or emergent visits for acute headache treatment documented in record.  After lengthy discussion, the Board concluded that the objective evidence of record fails to reflect “prostrating attacks” as defined above in the “last several months” proximate to separation.  Thus, the Board concluded that the evidence supports a 0% rating of the headaches condition at separation and no higher.  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 adjudication for the headaches condition.  

BOARD FINDINGS:  In the matter of the migraine HA condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140130, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Dear XXXXXXXXXX,
I am the Designated Decision Authority for the Coast Guard on applications submitted to the Department of Defense Physical Disability Board of Review (PDBR).  Under the authority of Title 10, United States Code, section 1554a, I accept the PDBR’s recommendation in your case (Case Number PD-2014-00688) and decline to modify your findings. 

Enclosed for your information are a copy of the PDBR’s recommendation and a copy of the record of proceedings. 

A copy of this decision has also been provided to Coast Guard Enlisted Personnel Management Branch, the PDBR, and the Department of Veterans Affairs. 

If you have any further questions, please contact the Coast Guard Personnel Service Center 
	Sincerely,

2 Enclosures		
	
Copy:	CG Personnel Service Center (EPM-1)
DoD Physical Disability Board of Review
Department of Veterans Affairs