RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02260
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020704

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty (Armored Crewmen) medically separated for chronic daily headaches.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  Chronic headaches, multiple type was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated chronic daily headaches as unfitting, rated 0%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions found unfitting and not unfitting by the physical evaluation board.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any condition 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 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:

IPEB – Dated 20020510	VA* - (~1 Mos. Pre-Separation)  -	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Daily Headaches	5399-5323	0%	Headaches, Non-Specific Mixed Type	5323-8100	10%	20020613	
Other x 0 (Not In Scope)	Other x 8	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20020709 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:

Chronic Daily Headache Condition.  The earliest note in the service treatment record (STR) dated 10 April 1995 indicated the CI had a headache with nose bleeds.  The headache started in the back of the neck and radiated to the parietal area bilaterally.  Treatment consisted of Robaxin (Methocarbamol, a muscle relaxer) and Motrin (Ibuprofen, a nonsteroidal anti-inflammatory drug [NSAID]) for the headache and bacitracin (an antibiotic) for the nose bleeds.  On 13 April 1995 the CI reported that while he was working on a tank and storage box, he fell and landed on his head.  Other than a laceration of the right side of the head, he had no other signs of injury.  Neurology evaluation in July 2001 indicated the CI had headaches almost daily for the past 1-½ years without nausea or vomiting.  Headaches began in the neck area and were bilateral.  The CI had automobile accidents with whiplash in the past, and as an armor crewman, he had to wear his helmet most of the time.  On examination there was percussion tenderness over C2 with some paracervical muscle spasm, but without any sensory abnormally over the scalp.  The remainder of the neurologic examination was unremarkable.  The diagnosis of occipital neuralgia secondary to muscle contraction-tension probably as a result of whiplash injuries and the helmet strap in the occipital area was made.  Treatment consisted of Neurontin (Gabapentin, for nerve pain).  Improvement was noted and limitation of the helmet use was recommended.  After an Emergency Room (ER) visit in November 2001, a neurologist diagnosed the headaches as chronic, non-specific occipital daily headaches with mixed features of muscular/tension refractory to extensive attempted treatments.  Additional treatment considerations included Depakote (Divalproex, seizure medication used for headaches) or Elavil (Amitriptyline, an antidepressant used for nerve pain) or a trial of occipital nerve blockade.  At a visit to the ER on 13 December 2001 the CI was noted to be taking Inderal (propanolol, a beta blocker), Imitrex (Sumatriptan, for migraine headaches), Topamax (Topiramate, for migraine headaches, indomethacin (an NSAID), and Midrin (Isometheptene, Dichloralphenazone, and Acetaminophen for migraines) for headaches; however the CI required and received needed intramuscular Toradol (Ketorolac, an NSAID) to successfully ameliorate the headache.  The CI had another ER visit for an acute headache on 4 May 2002, which was treated with Toradol, Demerol (Meperidine, a narcotic), and Phenergan (Promethazine, for nausea).

A permanent P3 profile was issued in January 2002 for chronic headaches with limitations of wearing a helmet.  The commander’s statement dated 23 January 2002 indicated the CI was physically incapable of performing his duties as an armor crewman due to his chronic headaches.  At the MEB examination, the CI reported on DD Form 2807-1, Report of Medical History, dated 30 January 2002 “When I have my migrans [sic] I’ll vomit and want to faint.”  The MEB physical examiner noted on DD Form 2808, Report of Medical Examination, dated 30 January 2002 the CI had pain on forward flexion and extension of the cervical spine.  The MEB narrative summary (NARSUM) dated 24 April 2002, 2 months prior to separation, noted the CI’s medical history and indicated he had an MRI in August 2001, which was normal without intracranial or extra-cranial pathology.  Neurological examination was unremarkable and pain was not reproduced with occipital percussion.  At the time of the NARSUM the CI complained of daily headaches with exacerbation noted with direct pressure of the neck such as use of a Kevlar or LBE (load bearing equipment).  Pain was also noted with running and other exertional activities such as sit-ups and push-ups.

At the VA Compensation and Pension (C&P) examination dated 13 June 2002, performed less than a month before separation, the CI reported that none of his medications worked.  He had a headache 24 hours a day, 7 days a week; and, the headache became worse with any type of physical activity.  The CI sited an incident in 1995 when he experienced head trauma with loss of consciousness for several seconds although he denied being diagnosed with any concussion or treated for any brain injury.  He had no seizures, chronic sinus infections, or hypertension.  The headaches were alleviated by going to bed and sleeping.  On examination there was some stiffness of the cervical spine with slight decreased flexion in bilateral bending, but no pain.  Neurologic evaluation was unremarkable.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5399-5323 (Group XXIII.  Function:  Movements of the head) for non-specific, mixed type, chronic daily headaches.  The VA assigned a 10% rating using code 5323-8100 (Migraine) for headaches.  The Board sought a route to a higher rating and examined rating options IAW VASRD codes 5323, 8100, and 8045 (Residuals of traumatic brain injury).  Code 5399-5323 does offer a 10% rating for moderate impairment of Group XXIII muscles and a 20% rating option for moderately severe involvement of Group XIII muscles, which on repeated examinations have been tender.  The CI’s inability to wear a helmet required by a tank team members and exacerbation of the headaches with movements of the neck suggest and support that code’s applicability with at least a 10% rating and even more so with a 20% rating, especially since multiple medications directed to ameliorating or eliminating the headaches have not been particularly effective.  The Board also considered a 30% rating using code 8199-8100 or 5323-8100; however, there was no evidence of characteristic prostrating attacks occurring on an average once a month over the last several months, although the CI did have three emergency room visits between November 2001 and May 2002.  Although the CI reported an incident of head trauma, the STR provided limited medical evidence to support a rating using code 8045, which at the maximum would be 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a disability rating of 20% for the chronic daily 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 chronic daily headache condition, the Board unanimously recommends a disability rating of 20%, coded 5399-5323 IAW VASRD §4.73.  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 his prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Daily Headache	5399-5323	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140522, 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

XXXXXXXXXXXXXXXXXXXXX

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20160004382 (PD201402260)

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,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization 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:

CF:
DoD PDBR
OVA