RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03378
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040514

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Guard, E-4, Food Service, medically separated by the Informal PEB (PEB) for “migraine headaches” with a disability rating of 0%. 

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:  

SERVICE PEB - 20040406	VARD - 20040623	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine Headaches	8100	0%	Migraine Headaches	8100	30%	20040623
20040802	
RATING:  0%	RATING:  40%	

ANALYSIS SUMMARY:  

Migraine Headaches.  The narrative summary noted the CI reported daily headaches (HAs) since February 2003, shortly after being called to active duty.  Notes in the service treatment record indicated the CI experienced a heat related illness in March 2003 with symptoms of HAs, tingling on the right side of her face, vomiting, chest pain and shortness of breath.  The CI had repeated episodes of similar symptoms over next few weeks during training and her command requested that she be fully medically evaluated.  A cardiology evaluation on 15 April 2003 noted a recent history of syncope (loss of consciousness) four times, associated with chest tightness.  A complete cardiac evaluation identified no cardiac cause of the symptoms.  The CI was seen by primary care for an acute visit on 5 August 2003 due to HA for the last 3-4 weeks and was placed on 36 hours quarters.  She was referred to neurology and was diagnosed with migraine HAs.  The neurologist thought the syncope was vasovagal syncope (“fainting”), not due to a central nervous system problem such as seizures.  The CI was advised to stop over the counter analgesics due to concern for rebound HAs and she was started on medications for prevention of migraine HAs (Topomax) and for self-treatment of acute migraine HAs (Zomig).  A magnetic resonance imaging scan of the brain was normal.  The CI went to sick call on 19 September 2003 for increasing HAs and reported she was out of medication and the sick slip indicated she was returned to duty.  

At a follow-up neurology visit 24 November 2003 the CI reported using Zomig once per week (down from multiple times per week) with partial relief of HAs and neck pain.  At a neurology visit 9 January 2005 the CI again reported daily HAs with frequent use of Zomig and she reported HAs were “to the point I can’t function” 4 days per week (needs to lie down).  Her medications were changed and she was given multiple trigger point (TP) injections in the neck.  The CI reported improvement at a follow-up visit 17 February 2004, noting HAs reduced to twice per week since the TP injections and starting a new preventive medication (Verapamil).  The commander’s statement noted that the CI was unable to work in warm temperatures, due in part to the migraine HA condition as well as her history of heat related illness, and that this limited her ability to perform the duties of her military occupational specialty in the field.  There was one episode of quarters prescribed specifically for migraine HA in record and this was the only episode of quarters in record in the 12 months before separation.  Between 12 and 14 months before separation there were an additional 3 episodes of quarters – two prescribed for the constellation of symptoms noted following the heat injury, which included HA in one instance, and one with no explanation provided.  At the Medical Evaluation Board (MEB) exam dated 23 February 2004, the CI reported daily HAs with interruption of work activity multiple times per week.  The MEB examiner noted there had been no emergency room or unscheduled visits for acute pain.  The MEB physical exam was normal with no neurological abnormalities.  The MEB examiner noted the migraine HAs limited the CI’s effectiveness at work.  

At the VA Compensation and Pension (C&P) exam on 23 June 2004, a month after separation, the CI reported HAs were throbbing associated with nausea and dizziness, and also extended to the back of the neck and caused tightness.  The physical exam was normal, without any neurological abnormalities.  The VA examiner indicated the CI had tension HAs, which seemed related to stress, with a vascular component to the HAs that did not fulfill criteria for a diagnosis of migraine.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and the VA both coded the migraine HA condition 8100.  The PEB rated the HA condition 0%, coded 8100, and noted that the HAs did not meet the criteria for “prostrating headaches” and the VA rated it 30% for “characteristic prostrating attacks occurring on an average of once a month over the last several months.”  The Board noted that the PEB may have relied on DoDI 1332.39 for its rating, which included a definition of “prostrating” as “the Service member must stop what he or she is doing and seek medical attention.”  However, the VASRD does not provide a definition of “prostrating attacks,” but uses the “clear English definition of prostrating.”  The Board first discussed definitions of prostrating; and, for its rating deliberations, all members stipulated to the definition of prostrating as “extreme exhaustion or powerlessness,” often cited by the VA in its rating decisions.  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 carefully considered the frequency and nature of the CI’s headaches including subjective evidence and corroborating objective evidence.  The PEB DD Form 199 noted that the CI had headaches frequently that caused her to lie down.  The MEB exam noted daily HAs, but a week earlier at a neurology follow-up the CI reported that she was having approximately two headaches per week following the last medication changes.  There was lengthy discussion whether the need to rest long enough to take current migraine medications to relieve HA and return to work was sufficient for a HA to be characterized as prostrating.  The Board majority did not think that a rest period by itself was enough to define a HA as prostrating and noted that there was no evidence in the record that the CI left work, missed work, or sought urgent care frequently due to migraine HAs.  The commander’s statement did not note loss of work time as an issue for the unit, which seemed to the Board majority incongruous with HAs four times per week, if prostrating.  At the C&P Neuro exam a month after separation, there was no documentation of the frequency of the HAs or how often, if at all, a HA was prostrating.  During discussions, the Board noted that only one period of quarters due to migraine HA was documented in the 12 months before separation, and even if the three additional periods of quarters in record were conceded as all related to the migraine HA condition, this equaled six “prostrating attacks” in the 14 months before separation.  This does not literally meet the 10% rating criteria of prostrating attacks “averaging one in two months over the last several months,” however; Board consensus was that with consideration of VASRD §4.3 (reasonable doubt) and §4.7 (Higher of two evaluations) a 10% rating was supported, but that it would be overly speculative to recommend the next higher rating of 30% based on the evidence.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 and §4.7, the Board majority recommended a disability rating of 10% for the migraine HA condition.  

BOARD FINDINGS:  In the matter of the migraine HA condition, the Board majority recommends a disability rating of 10%, coded 8100 IAW VASRD §4.124a.  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, effective as of the date of the prior to medical separation:  

CONDITION	VASRD CODE	RATING	
Migraine Headaches Condition	8100	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140627, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	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 XXXXXXXXXXXXXXXXXXXX, AR20160005030 (PD201403378)

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 10% 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
(  ) DVA