RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00814
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20081202

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

CI CONTENTION:   The CI contends he experienced an average of 2-3 prostrating migraines a month and that his military work productivity dropped significantly after he underwent a spinal tap on 24 July 2007.  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 based upon a 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 - 20080905	VARD - 20101106	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Hemiplegic Migraines…	8100	10%	Hemiplegic Migraines	8100	0%	20101012	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Hemiplegic Migraine Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI complained of migraine headaches approximately 1 year prior to MEB referral.  An emergency department encounter on 24 July 2007, documented one such episode.  A head diagnostic imaging (CT) study on 24 July 2007 was unremarkable.  Cerebrospinal fluid (CSF) from a 25 July 2007 lumbar puncture (LP) was unremarkable.  A brain diagnostic imaging (MRI) study on 7 August 2007 was normal.  Head and neck magnetic resonance angiograms (MRA) were conducted on 7 August 2007 to visualize blood vessels and were normal.  An 8 August 2007 echocardiogram was essentially normal and without evidence of obvious source of cardioembolic phenomena (heart source of clot occluding blood to brain).  

An 18 September 2007 neurology encounter documented “A couple of months ago he had three spells of some kind where he was semi-coherent and talks about maybe hitting his head on the headboard of his bed and some knee discomfort without true loss of consciousness although he had some difficulty remembering portions of it.  These three episodes lasted anywhere from 45 seconds to a minute and one of them, i.e. the third one, was associated with paralysis of the left side for about an hour.  He also had headache during that time.  He describes talking to a lady friend and was told that he was mumbling and talking incoherently during that time.  Approximately two weeks later from those episodes he was in a car and had an episode of left-sided weakness including the face, arm, and leg lasting perhaps up to a couple of hours.  He did have headache again associated with that.”  

The neurologist opined “I suspect these could be complicated migraine…because he did have weakness associated with this there is a familial hemiplegic migraine [motor aura manifestation of unilateral weakness accompanying migraine headache].  A 12 December 2007 routine and sleep deprived electroencephalogram ([EEG] diagnostic test to assess for epilepsy) was normal during both wakefulness and drowsiness.  A 10 March 2008 evaluation by a second neurologist documented the CI “had some headaches with episodes of hemiplegia (partial/total paralysis of one side of body) that have been transient starting back in the fall of last year.”  A 14 May 2008 neurology follow-up documented “Patient states the he does not want to take Inderal.  Patient states that he doesn’t feel he needs it because he has only had one headache and no seizure activity.”

In the 20 June 2008 MEB addendum, the CI reported daily headaches with seven occurrences where he experienced a hemiplegia (last episode in February of 2008).  He complained of headaches associated light and sound sensitivity, but denied nausea and vomiting.  The CI discontinued his Topamax (anticonvulsant) for headache prophylaxis because of questionable adverse effects (tremor and memory loss).  He occasionally used Zomig (triptan) as needed to abort headaches, but refused to take Inderal (beta blocker) for headache prophylaxis.  The examiner recounted that the genetic testing for familial hemiplegia migraine was indeterminate.  Under recommendations regarding the CI, the examiner documented “He is not convinced that he has migraine headaches and he feels that since he has not had an episode of hemiplegia with his last headache occurring in February 2008, there is no need to start on the Inderal.”  

Despite treatment, the migraine headache condition could not be adequately treated to meet the physical requirements of the CI’s military specialty.  The MEB forwarded “migraines” for PEB adjudication.  Review of the STR revealed no documented encounters of care for headaches during the several months before separation, though daily headaches were reported by the CI.  The most proximate documented headache event, which was prostrating (ER visit with bedrest) occurred on 18 February 2008, 10 months prior to separation.  The STR fell silent with regard to care for headaches between 14 May 2008 and the date of separation, leaving a 7-month gap in documented treatment of headaches.  The undated commander’s statement, reported a concern for the welfare of the CI and other firefighters, as well as a refusal to take prescribed medication.  It also noted that the last known migraine headache had occurred in February 2008.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 8100 code (migraine) citing hereditary type hemiplegic migraines, no headache since February 2008, and “no prostrating attacks occurring on an average of once a month over last several months.  The VA assigned a 0% rating under the 8100 code (migraine) based on the VA C&P examination 22 months after separation, citing medical evidence did not show the severity of the condition met compensable criteria.  Noting the temporal relationship to the date of separation (22 months), the Board assigned little probative value to the VA C&P examination.  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, but commonly accepted definitions include “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 considered the totality of available evidence in the treatment records in order to most accurately assess the overall disability picture (§4.2) at the time of separation.  Review of the record did not reveal objective evidence of prostrating headaches occurring on average once per month, or more frequently, over the last several months prior to separation to support a rating higher than the 10% adjudicated by the PEB.  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 hemiplegic migraines.  

BOARD FINDINGS:  In the matter of the hemiplegic migraines and IAW VASRD §4.124, 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 20150602, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00814.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXXXX

Attachment:
Record of Proceedings