RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01071
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091221

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Cannon Crewmember, medically separated for “post concussive headaches evaluated as residuals of traumatic brain injury (TBI),” with a disability rating of 10%.

CI CONTENTION:  He was given a higher rating for his headache condition by the VA.  His 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 - 20091118	VARD - 20100315	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Concussive Headaches Evaluated as Residuals of TBI	8045	10%	Migraine Headaches	8045-8100	30%	20100216	
			Traumatic Brain Injury	8045	0%	20100216	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Post Concussive Headaches Evaluated as Residuals of TBI.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s headaches began in childhood but he did not seek medical attention for them.  His headaches were responsive to over-the-counter Tylenol with the exception of a headache he had at age 10 that lasted for 2 days.  The CI reported that his headaches began to surface again during his deployment to Iraq after exposure to IED blasts.  After returning from Iraq, he was referred to neurology and prescribed varying trials of medication to abort and prevent the headaches.  A magnetic resonance imaging (MRI) in April 2008 recorded no intracranial abnormality.  Neurology notes indicated that an initial diagnosis of common migraine was made in May 2008, and later changed to post-concussion syndrome in July 2009.  On 3 November 2008, the CI presented to the emergency room (ER) with the complaint of a headache; however, during the wait, his headache improved and he left without being evaluated.  There were no other recorded visits to the ER related to this condition.  Despite treatment, the headaches could not be adequately treated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  

The NARSUM dated 8 October 2009, noted that the CI had about three headaches per week and was taking one abortive and one preventative medication.  His headaches were sharp and “always on the left side” with a pain intensity of 10/10 and he noted sensitivity to light/sound accompanied by nausea.  The CI reported that when he got a headache, he took an abortive medication and went to dark room; the headache could last from 45-90 minutes.  The CI also reported headaches after running but not during the activity.  A mental status examination was normal with the CI achieving 30/30 on cognitive testing; the examiner stated there were “no signs of any underlying significant cognitive impairment.”  The examiner referenced a clinic note (not in evidence) dated 8 July 2008 that reportedly assessed a facet score “1-2” for subjective headaches, and “1” for neurobehavioral symptoms. The CI noted that he had been referred to mental health but did not feel he had any mental problems.  It was noted that in March 2009, he was cleared by mental health for deployment.

At the VA Compensation and Pension examination on 16 February 2010, 2 months after separation, the CI said he had about six headaches per month and reported most were prostrating.  The examiner did not describe the intensity of the headaches, how long they lasted, or what measures the CI took to relieve them.  There was no comment regarding subsequent impairment associated with the headaches but the examiner noted that the condition had no effect on usual daily activities.  The CI indicated he had no problems with memory, coordination, or sleep, and mental health symptoms were absent.  Both physical and neurological examinations were normal.  A diagnosis of mild stable TBI with residuals of mild migraine headaches was assessed.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the headache condition 10% using code 8045 (residuals of TBI) citing that neuropsychological testing demonstrated no cognitive issues and that the facet related to subjective symptoms was met at the 10% level (total facet of 1) for headaches.  The VA rated the condition as residuals of TBI at 0% coded 8045, and also rated analogously to migraine headaches at 30%, coded 8045-8100, based on “prostrating headaches, occurring on an average of once a month over the last several months.”  The Board undertook a careful review of the record in evidence for support of a rating higher than the 10% under the 8045 code.  The Board is required to evaluate cognitive disorder IAW VASRD 4.124a.  The VA assigns an evaluation based upon the highest level of severity for any facet (there are 10 facets with “3” as the highest level) of cognitive impairment and other residuals identified as associated with the condition.  The higher rating of 40% requires demonstration of an impairment level corresponding to level 2.  The NARSUM indicated that the subjective symptoms of headaches were judged to be “1-2.”  Under subjective symptoms, a “1” is consistent with mild impairment and a “2” represents moderate impairment.  However, a headache score of “1” represents headaches that are mild-moderate, and a “2” is granted when the headaches requires rest periods during most days.  The record documented headaches that had decreased in frequency to 3 per week.  The CI noted that his headaches were of 45-90 minute duration, and he often took brief rest periods in a dark room. The commander’s statement (CS), 6 months before separation, made no mention of severity of headaches, nor was it stated that the CI had to isolate himself in a dark room due to headaches.  There was no indication that he had to leave work to seek medical attention for his headaches. The VA C&P examiner diagnosed mild headaches.  All Board members agreed that there was insufficient evidence to support that the CI’s headaches were more than mild to moderate in intensity.  Therefore, Board members concluded the level “2” impairment was not met, and that his condition best reflected a facet “1” score.  The Board also considered rating options using code 8100 (migraine headaches) which 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).  The Board carefully considered the frequency and nature of the CI’s headaches including objective and corroborating subjective evidence.  The 10% rating under this code requires one prostrating headache in 2 months over the past several months.  The higher rating of 30% requires once monthly over several months of prostrating headaches.  The Board could not find one single headache meeting the criteria or description of prostrating attacks with the possible exception of the CI’s visit to the ER in November 2008 with complaint of a migraine headache; however, while waiting to be seen, his headache resolved and he left the ER.  Although the PEB indicated that the CI reported he presented to the ER in January or February 2009, STRs failed to demonstrate any ER visits beyond November 2008.  The Board noted that evidence of incapacitating episodes and prescribed quarters was absent.  All Board members agreed that there was insufficient evidence that the CI suffered prostrating headaches arising to the 30% level and concluded that using code 8100 offered no benefit to the CI.  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 of the residual of traumatic brain injury condition.  

BOARD FINDINGS:  In the matter of the post-concussive headaches evaluated as residuals of TBI 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 20140220, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency (AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA   22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX AR20160005843 (PD201401071)

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 and hereby deny the individual's application.
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

 

Enclosure 

CF:
(  ) DoD PDBR 
( ) DVA