RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03728
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Chaplain Assistant, medically separated for “migraine headaches,” with a disability rating of 10%.  

CI CONTENTION:  “Migraines, also please consider all conditions.”  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 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 – 20080417	VARD - 20080519	
Condition	Code	Rating	Condition	Code	Rating	Exam	
…Migraine Headaches…	8100	10%	Migraine Headaches	8100	10%	20080519	
Chronic Allergic Rhinitis	Not Unfitting	Allergic Rhinitis	6522	0%	20080519	
RATING:  10%	RATING:  50%	

ANALYSIS SUMMARY:  

Migraine Headaches (Basilar Artery).  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI has had a history of migraine headaches since May 2007, which have been treated with various abortive and prophylactic medications (Midrin, Tryptans, beta-blockers, and calcium channel blockers).  Despite treatment, the CI’s migraine headache condition could not be adequately treated to meet the physical requirements of the CI’s military specialty and was referred for an MEB.  At the time of the neurology clinic appointment on 12 September 2007 (11 months prior to separation), the examiner recorded the CI had  four events of loss of consciousness since May 2007, all of which were preceded by severe posterior headaches.  Three of these events were provoked by heat and exertion.  The neurologist concluded that her symptoms were not due to a seizure disorder and diagnosed her with basilar artery migraine headaches.  The CI stated that she had headaches almost every day that occured twice a day and lasted between 90-120 minutes.  At a follow-up with neurology on 3 October 2007 (11 months prior to separation), the CI stated that she had had one migraine that was milder than before and lasted 2 hours and she just “dealt” with it.  She was released without limitations.  At a subsequent neurology clinic appointment on 25 October 2007 (10 months prior to separation), the CI stated that she “had 2 migraines last week and 3 this week,” but the examiner noted that she had not missed work or gone to the emergency department during those 2 weeks.  She was released without limitations.  On 7 December 2007 (8 months prior to separation), the CI emailed a headache log to the neurologist, which covered a two week period from 26 November through 6 December 2007.  The log reflected that she had had one migraine in the evening on 1 December 2007 with photophobia that lasted 2.5 hours.  On 13 December 2007 (8 months prior to separation), the CI presented to the TMC.  The examiner recorded that her migraines were usually located in the back of her head, but that her headache today was in the frontal region.  She was diagnosed with acute sinusitis with headache episode being caused by sinus infection.  She was placed on quarters for 24 hours.  On 7 January 2008 (7 months prior to separation), the CI presented to the neurology clinic.  The examiner recorded that she was having 2-3 headaches per week consistent with migraines that reached the 6 of 10 pain level.  The CI stated that getting more rest helps her headaches a great deal.  She was released without limitations.  

The MEB NARSUM, dated 15 January 2008 (7 months prior to separation), noted that the CI deployed to Iraq in July 2007 and soon after arriving there started having headaches at the rate of two to three times a week.  The headaches affected her vision and made her ears ring.  Loud noises or bright lights would aggravate her symptoms.  The CI reported that she occasionally vomited when she had a headache.  The CI also reported that her headaches were “currently” occurring two or three times per week and affected her ability to perform her military duties.  She also said that she tried to work through her headaches, but they still caused her to miss a few hours of work each day and they also decreased her efficiency.  The MEB physical exam, dated 16 January 2008, was unremarkable.  On 21 February 2008 (6 months prior to separation), the CI presented to the Community Care Center.  The examiner recorded that the CI had been having a migraine for 2 days in the left posterior occiput.  The CI stated that she had 8 of 10 stabbing pain.  On examination she was noted to have photophobia and tinnitus.  The CI was treated with medication and released with work/duty limitations.  The treatment records fell silent with regard to care for headaches between 21 February 2008 and the time of separation, 6 months later.  The commander’s statement, dated 7 March 2008 (5 months prior to separation), reported that the CI had been able to perform duties assigned to her within the limits of her profile.  A letter of recommendation from her NCOIC, dated 10 March 2008, stated that she showed up to duty on time every day.  The Formal PEB, which included sworn testimony, was dated 17 April 2008 (4 months prior to separation).  

At the VA Compensation and Pension (C&P) examination on 19 May 2008, performed 3 months prior to separation, the CI reported that when headaches occurred, she had to stay in bed and was unable to do anything.  Her headaches occurred on the average of three times per month and lasted for two hours.  She said she treated them with Percocet and Midrin (abortive medication) and reported that she did not experience any functional impairment from this condition.  Physical exam showed she was in no acute distress.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the headache condition 10% (code 8100 migraine) citing “ALTA records [show] acute care visits averaging one in every two months for migraines.”  This was likely application of DoDI 1332.39 (rescinded after the CI’s MEB and prior to separation) which 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.  The VA rated the headache condition 10% (code 8100) citing characteristic prostrating attacks averaging one in two months over the last several months and stating:  “although you report frequency of attacks occurring three times a month, characteristic prostrating attacks are not documented by your treatment records.”  Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months.”  The VASRD does not further define prostrating attacks; however, a common (court-sanctioned) approach is to apply the clear English definition of prostrating such as “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 evidence and corroborating subjective evidence.  There was no evidence in the record that the CI had very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability to support a 50% rating.  The Board therefore deliberated between the 30% criteria (characteristic prostrating attacks occurring on an average once a month over the last several months) and the 10% criteria (characteristic prostrating attacks averaging once in 2 months over last several months).  Review of all records in the 6 months prior to separation documented that headache citations were infrequent over the last several months prior to separation.  The Board weighed the CI’s reported frequency of attacks occurring three times a month with the supporting commander’s and NCOIC statements as well as the CI’s indication at the pre-separation VA exam that she did not experience functional impairment from the migraine condition.  

The Board adjudged that there was insufficient reasonable doubt to support that the CI had “characteristic prostrating attacks occurring on an average once a month over last several months” to support a rating higher than 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the migraine headache condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that allergic rhinitis was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The allergic rhinitis was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The allergic rhinitis condition was reviewed and considered by the Board.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  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 fitness determination for the contended condition and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the migraine headache condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended allergic rhinitis condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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 20140619, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		
MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160009328 (PD201403728)

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