RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03031
BRANCH OF SERVICE:  Army	
DATE OF PLACEMENT ONTO TDRL:  20051013	DATE OF REMOVAL FROM TDRL:  20060919

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Chemical Operations Specialist) medically separated from the Temporary Disability Retired List (TDRL) for a “migraine headache” condition rated at 0%.  

CI CONTENTION:  The applicant makes no specific contention in her application.  The CI’s 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 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 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:  

Final PEB – 20060906	VA Rating Decision1 - 20060202	
TDRL Placement – 20051013	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL3 Removal	
Chronic Daily Headaches and Migraines with Aura	8100	30%	0%	Migraine Headaches	8100	30%	30%	
Other x 0 (Not in Scope)	Other x 20	
RATING:  30% → 0%	RATING:  80%	
1. Most proximate to TDRL Placement
2. Rating derived from C&P exam dated 20050920, ~1 mo. pre-TDRL placement
3. Rating derived from C&P exam dated 20050920, ~12 mos. pre-TDRL removal 

ANALYSIS SUMMARY: 

Headache.  The service treatment record (STR) documents that the CI began complaining of dizziness and headaches while on convoys in Iraq.  The craniofacial MRI was unremarkable and showed no central nervous system abnormality.  A neurology consultation documented the CI was referred for evaluation of dizziness which began in March 2004.  The dizziness had improved but the CI reported having constant daily headaches since March 2004.  Headaches involved the bilateral retro-orbital region with radiation to the bilateral fronto-parietal region.  The constant pain was associated with nausea, photophobia (light sensitivity), phonophobia (sound sensitivity), and blurred vision.  There was no diplopia (double vision).  Headaches were aggravated by movement and not aggravated with valsalva (forceful expiration with a closed glottis) or supine position.  The neurological exam was normal.  The assessment listed chronic daily headaches, which did not meet criteria for any of the common headache syndromes.  The neurologist reviewed the MRI of the brain and saw no structural etiology.  Zoloft (antidepressant) was started by a psychiatrist in February 2004 for depression.  The plan was to increase the dose of Zoloft for headache prophylaxis.  The neurology follow-up listed past treatments which included Tylenol #3, Advil, Indocin, Midrin, Zomig and Zoloft.  The impression listed chronic daily headache which was unresponsive to Zoloft.  The plan was to taper off the Zoloft and start titration (dose adjustment based upon response) of Topamax (anticonvulsant) for headache prophylaxis.  Neurology performed BOTOX (Clostridium botulinum neurotoxin that blocks neuromuscular transmission) injections to treat the chronic headaches.  The narrative summary (NARSUM) by neurology, 3 months before placement on TDRL, documented that headaches were typically retro-orbital, unilateral, and radiated to become more global within minutes to hours. The headaches were described as throbbing in nature and associated with left sided numbness and visual field defects.  Initially two headache preventives were attempted (Zoloft and Topamax) which were not effective at preventing, or reducing the duration or severity, of headaches. Indomethacin was somewhat effective in aborting the more severe attacks.  Other headache therapies were attempted (optimizing Topamax therapy, Keppra [anticonvulsant], Depakote [anticonvulsant], BOTOX injections) without significant improvement.  The CI complained of daily headaches, some extremely severe, requiring multiple emergency room (ER) visits for pain management.  She was unable to tolerate the more frequently used abortive triptans (Zomig, Imitrex) secondary to chest pain and increased blood pressure.  The headaches improved with bed rest and strong abortive medications (Fiorinal [barbiturate], Phenergan [antiemetic], Percocet [combination opioid analgesic]).  The CI would stay home during more severe attacks and took pain medication as prescribed.  No driving or work was recommended when taking the abortive drugs prescribed secondary to sedative effects.  She experienced daily headaches, more severe attacks every three days, and missed work at least once a week.  The physical exam revealed normal coordination and gait.  The motor exam showed normal muscle, tone, bulk, and strength.  The cranial nerve exam was unremarkable and the sensory exam was normal.  Deep tendon reflexes were normal, and pathological reflexes were absent.  The neurologist documented that the CI suffered chronic daily headaches and migraines with auras.  Auras involved episodes of visual field changes and left sided paresthesias (abnormal sensation, tingling, burning, prickling) and weakness. The headaches had been unresponsive to the multiple medications attempted.  The diagnosis listed migraines with aura.  Neurology performed bilateral greater occipital nerve blocks with injected local anesthetic for the constant occipital pain and neck stiffness.  This was followed by injection of local anesthetic between the 4th and 5th lumbar vertebra (L4-5) in an attempt to treat the chronic headaches.  A General Medical Compensation and Pension (C&P) exam was performed by a physician assistant, 3 months after placement on TDRL, and 12 months before removal from TDRL.  This was the sole C&P exam in the STR and cited in evidence in five VARDs spanning 2006 to 2014.  It documented the CI developed intermittent headaches in February 2004 which progressed to a constant headache.  The headaches could be caused by heat and usually started in the neck and migrated to the entire head.  They were associated with vertigo, noise sensitivity, light sensitivity, numbness to left side of face, and to the foot.  The CI stated she had exacerbations 2-3 times per week and that she missed 3-4 days of work per week.  The CI was treated with preventive and abortive medications (Depakote, Indocin, Aleve [NSAID], Percocet, Phenergan) and the headaches usually resolved in one day.  The physical exam revealed a normal posture and gait.  Muscle strength was equal bilaterally and without weakness.  Cranial nerves and sensation were intact.  Deep tendon reflexes (+2) were normal and pathological reflexes were absent.  The diagnoses listed migraine headaches.  Seven months after placement on TDRL, the neurology impression listed intractable migraine headaches with and without auras.  The neurologist advised the CI to stop using Indomethacin as this could trigger more headaches, especially migraines.  He advised that any pain medication should not be used more than two or three days in a week.  He planned another trial of a triptan, to see if she tolerated it without side effects, and a trial of a Verapamil (calcium channel blocker).  At the follow-up, the neurologist documented that the brain MRI was essentially normal and the cervical spine MRI was unremarkable for any significant spondylotic disease (spine degeneration) or herniated disc.  The impression listed intractable migraine headaches, not responsive to any medications, and myofascial pain and muscle spasms affecting the left neck and shoulder.  For the migraines, he planned to continue the Verapamil and Zoloft and start her on Depakote, Midrin, Ultram (opioid-like analgesic), and Zanaflex (alpha agonist).  If the myofascial pain syndrome continued, he planned Myobloc (Botulinum toxin type B that blocks neuromuscular transmission) injections in the cervical and shoulder muscles.  The NARSUM by neurology, 12 months after placement on TDRL referred to the pre-TDRL NARSUM for the CI’s clinical history.  Active preventive medications were Depakote, Zoloft, and Verapamil.  The CI reported no response had been noted so far.  She complained of daily headaches, some extremely severe, requiring multiple ER visits for pain management.  The headaches improved with bed rest and abortive medications.   The CI was unable to tolerate the more frequently used abortive triptans.  Abortive medications, prescribed by a civilian neurologist, were Ultram, Naproxen, Duradrin (combination analgesic/sedative/sympathomimetic), and Phenergan.  She experienced daily headaches, more severe attacks every 3 days, and missed work at least once a week.  During more severe attacks she stayed home and took pain medication as prescribed.  The CI had just started her third job since being placed on TDRL and reported severe difficulty with staying employed due to frequent headaches.  The physical exam revealed normal coordination and gait.  The motor exam showed normal muscle, tone, bulk, and strength.  The cranial nerve exam was unremarkable and the sensory exam was normal.  Deep tendon reflexes were normal, and pathological reflexes were absent.  The diagnoses listed chronic daily headaches, and migraines with auras, that had been unresponsive to multiple medications.  The CI failed to comply with the PEB request for a medication profile.

The Board directed attention to its rating recommendation based on the above evidence.  The Board first considered its rating recommendation at the time of placement on TDRL.  The Informal PEB rated the headache condition at 30% (VA code 8100; migraine [headaches]).  The PEB cited chronic daily headaches, migraines with aura, poor response to therapy, and missing work at least once a week.  The VARD, 12 months after placement on TDRL, citing the C&P exam 3 months after placement on TDRL, rated the migraine headaches at 30% (8100).  The rating options under 8100 for migraine headaches, which are open to consideration in this case, rely on the frequency of ‘prostrating’ attacks.  The DoDI 1332.39 (in effect at separation, but since rescinded) required that “the Service member must stop what he or she is doing and seek medical attention.”  However, VASRD §4.124a does not require seeking medical attention for an attack to be considered prostrating, and a common (court-sanctioned) approach is to apply the clear English definition of prostrating.  The Board carefully considered the frequency and nature of the CI’s headaches including objective evidence and corroborating subjective evidence.  While the NARSUM neurologist did not specify characteristic prostrating attacks, he documented “more severe attacks once every 3 days.”  The estimation of the social and industrial impairment could be inferred from “is currently missing work at least once a week.”  Board members agreed the headache condition did not approach the 50% rating (with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability).  A rating higher than the 30% (with characteristic prostrating attacks occurring on an average once a month over last several months) adjudicated by the PEB is not supported by the evidence.  
The Board next considered its recommendation for permanent disability rating at the time of removal from the TDRL.  The sole basis for the Board’s permanent disability recommendation is the optimal VASRD rating for disability at the time the CI is permanently separated at removal from TDRL.  The Informal PEB, 14 months after placement on TDRL, rated the migraine headache condition at 0% (8100).  The PEB documented although the CI stated to the neurologist that she had required multiple ER visits, no documentation of these visits was provided, and no documentation was provided that she was currently on the stated medications.  The rebuttal of the PEB findings documented “the PEB has found your rebuttal contained no new objective medical or performance evidence which would warrant a change to the original findings.”  The NARSUM neurologist documented “more severe attacks once every 3 days” and “is currently missing work at least once a week.”  These findings reflect the CI’s self-reports of attacks and impairment.  These claims could not be substantiated because the CI did not provide documentation of multiple ER visits, or her current medication profile.  The CI had several opportunities to submit this requested documentation but failed to provide it before the PEB, or with the rebuttal of PEB findings.  The STR did contain a copy of her medication profile, faxed 6 weeks after the request, and a week after the PEB convened.  The medication profile contained the civilian neurologist prescribed Depakote, Zoloft, Verapamil, Ultram, Duradrin and Phenergan.  Board members agreed the headache condition did not approach the 50% rating.  The Board members agreed that the totality of evidence is consistent with the 30% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a permanent disability rating of 30% for the headache condition at the time of removal from the TDRL.

BOARD FINDINGS:  In the matter of the headache condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication at TDRL placement and a disability rating of 30%, coded 8100 IAW VASRD §4.71a at TDRL removal.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	TDRL	RATING	
Chronic Headaches and Migraines with Aura 	8100	30%	30%	
COMBINED	30%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140602, 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, AR20160005006 (PD201403031)

1. Under the authority of Title 10, United States Code, section 1554(a), I approve the
enclosed recommendation of the Department of Defense Physical Disability Board of
Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize
the individual's separation as a permanent disability retirement with the
combined disability rating of 30% effective the date of the individual's original medical
separation for disability with severance pay.

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:

a. Providing a correction to the individual's separation document showing that
the individual was separated by reason of permanent disability retirement effective the
date of the original medical separation for disability with severance pay.

b. Providing orders showing that the individual was retired with permanent
disability effective the date of the original medical separation for disability with
severance pay.

c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will
account for recoupment of severance pay, and payment of permanent retired pay at
30% effective the date of the original medical separation for disability with severance
pay.

d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP)
and medical TRICARE retiree options.

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:

Enclosure
CF:
( ) DoD PDBR
( ) DVA