RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03303
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20061116

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Unit Supply Specialist) medically separated for migraine headaches, rated at 10%.  

CI CONTENTION:  “Please consider all conditions.”

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 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:  

IPEB – Dated 20060927	VA* - (~6 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine Headaches	8100	10%	Migraine Headaches	8100	10%	20070614	
Other x 0 (Not In Scope)	Other x 6	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20070808 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Migraine Headache Condition.  The narrative summary (NARSUM) noted the CI developed headaches (HA) in September 2004 that became more frequent and were often precipitated by physical exertion.  Notes in the service treatment record indicated that the CI was diagnosed with migraine HA by primary care (PC) and treated with abortive and preventive medications for migraines.  The HAs reportedly started after physical training in the morning and worsened throughout the day.  She was frequently seen by primary care or the emergency room for throbbing HA, associated with nausea and vomiting.  Computed tomography (CT) scan of the head was normal.  Some emergency visits indicated the CI had run out of her usual prescription medications.  At a neurology follow-up on 7 September 2005 the CI reported she had been on leave half way across the country for twelve days and did not have any HAs, but the HAs returned when she returned from leave, however, allergy medications seemed to have no effect on the HAs, but use of current migraine medications relieved the HAs.  According to the NARSUM at a field training exercise a few months before the MEB exam, the CI required treatment for migraine HA every other day by field medical staff.  Temporary profiles in record dated 7 September 2005 and 20 March 2006 indicated the CI could participate in physical training (PT) in air conditioning or at outdoor temperatures less than 85 degrees Fahrenheit.  The permanent profile dated 22 June 2006 indicated the temperature restriction and also “allow 2-3 hr breaks during more severe headaches…to take medication and rest”, but there was no restriction regarding PT or fitness test events.  The commander’s statement noted the CI’s profile restrictions, but did not document frequent absences or how often migraine HAs resulted in significant disruption of duty performance.

At the MEB exam performed 18 August 2006, 3 months before separation, the CI reported daily HAs.  The CI’s medications included abortive and preventive migraine medications.  The MEB physical exam was completely normal, including neurological exam.

The PEB requested additional information from the neurologist on 14 September 2006 regarding the frequency of “prostrating” migraine HAs and referred to the DoDI 1332.39 definition of prostrating HA, which includes that the Service member must stop what they are doing and seek medical attention.  The PEB noted that there had been no emergency visits for the HAs since September 2005 documented in the medical record.  In the NARSUM addendum 18 September 2006, the neurologist indicated that despite significant activity restrictions the CI had required emergency treatment for migraine HAs on 3 February 2006, 13 April 2006, and 17 April 2006 and indicated the neurology department had “worked aggressively to prevent the truly debilitating headaches.”  The neurologist also noted that the CI had participated in the field experience to see if she could tolerate routine military exercises and she could not, as verified by the unit’s treating medical providers and he emphasized that “on every occasion over the past 6 months that this soldier has been pushed in physical activity in temperatures over 80 degrees, she has been unable to continue due to development of headaches.”

At the VA Compensation and Pension (C&P) exam performed 14 June 2007, 7 months after separation, the CI reported she was currently employed working with the public.  She reported HAs every other day for 5 to 6 hours with relief from abortive medications “about 50% of the time”.  She reported she had to go into a darkened room and could not work “while she has one of her HAs.”  The VA exam was normal with regard to the migraine HAs, including normal neurological exam.  The VA examiner did not document any periods of incapacitation due to the HA condition or missed work time.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB and the VA both rated the migraine HAs 10%, coded 8100 (migraines).  The Board noted that the PEB may have relied on DoDI 1332.39 for its rating, which includes a definition of “prostrating” as indicated above.  However, the VASRD does not provide a definition of “prostrating attacks”.  Member consensus was that characterizing a HA as prostrating required some evidence that the CI was unable to continue to work for a significant length of time.  The Board considered the VASRD rating criteria for migraine HAs, which are increasing frequency of “prostrating attacks” for the 0%, 10%, and 30% ratings and additionally, the attacks “are productive of severe economic inadaptability” for the highest available rating of 50%.  The Board deliberated the evidence and agreed that both the MEB and C&P exams were vague regarding the frequency of prostrating HAs “over the last several months”.  The Board noted that in the response to the PEB’s request for clarification regarding the frequency of incapacitating headaches, the MEB neurologist noted that the reduction in the CI’s debilitating headaches required restrictions and multiple medications.  However, as noted the rating criteria are dependent upon the recent frequency of “prostrating headaches” and not the use or types of medication required for management.   Before separation, there were three visits for emergency medical treatment within nine months of separation (and also within 12 months of separation), excluding the field training exercise, and as clarified by the neurologist the most recent was 7 months before separation.  The NARSUM noted that when the CI was again subjected to known precipitating factors during the field training, the HAs flared-up.  The neurologist emphasized that the development of HAs was routinely associated with physical exertion in elevated temperatures.  The Board agreed that this demonstrated that despite treatment the migraine HAs were unfitting for continued military service, but this was not otherwise indicative of the status of the HA condition with restrictions, or as anticipated in a non-military environment after separation.  Following evaluation and treatment by the specialist, the evidence supports that the CI’s migraine HAs were improved, but not completely controlled.  After separation, at the C&P exam the CI reported frequent HAs and being unable to work with these HAs.  However, the Board noted the CI was working in a position dealing with the public and she did not report leaving work or missing work frequently.  After deliberations, the Board agreed the evidence in record did not support a higher rating than supports 10% rating at separation as the next higher 30% rating for prostrating attacks “on average once a month” would require undue speculation.  After due deliberation in consideration of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the migraine 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 20140428, 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 AR20160004514  (PD201403303)

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