RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01555
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060505

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Health Services Management Journeyman, medically separated for “complicated migraine, with hemiplegia with chronic daily headaches (EPTS) and psychological factors affecting migraine” with a disability rating of 20%.  

CI CONTENTION:  The CI requested a review of all conditions.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel's scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the panel for Correction of Military Records.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determinations is based on 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 panel 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 panel 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 - 20060223	VARD - None	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Complicated Migraine, with Hemiplegia, with Chronic Daily Headaches (EPTS) and Psychological Factors Affecting Migraine	8100	 20%	No VA Examination in Evidence	
Cervical Dysplasia	Cat II		
Chronic Tonsillitis			
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Complicated Migraine with Hemiplegia.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s headache condition began at age 15 but increased in severity in December 2004 related to high stress.  Over the next year the CI had been seen by four primary care providers and one ER physician for her migraines with multiple visits to the clinic, ER and specialty care clinics for pain management and neurology since December 2004.  She was evaluated by neurology on February 3, 2005 and the CI was assessed to have complex headache symptoms most consistent with transformed migraine following complicated migraine with stroke based on a permanent right temporal inferior quadrant visual field defect after a debilitating migraine.  Migraine headaches occurred about four times per month (weekly) described as sharp and throbbing typically 10/10 pain.  The migraine headaches could last up to 4 days when not treated, they usually lasted for about 2 days and were accompanied by severe nausea, but not by vomiting.  She also reported daily headaches described as dull 2-5/10 pain level.  A Magnetic resonance imaging (MRI) and repeat orbital MRI were both normal.  The MEB forwarded “complicated migraine with stroke,” “chronic daily headaches,” and “psychological factors affecting migraine” for PEB adjudication.  

At the Military Entrance Processing Station (MEPS) entrance examination (recorded on DD Forms 2807 and 2808) dated 22 July 2002, the CI marked ‘no’ to the question of “have you ever had or do you now have frequent or severe headache?”  However, the CI reported that she was currently taking Tylenol for headache.  Physical examination was normal and rated the headache as insignificant.  At the Neurology evaluation on 3 February 2005, 15 months prior to separation, the examiner noted that the CI had a history of migraine with visual aura since adolescence.  Early in the course of these {migraine} symptoms a sudden onset of loss of vision in the right monocular lower temporal field which had remained constant since that time.  Physical and Neurological examination was significant for right occipital-cervical trigger point consistent with right greater occipital neuralgia.  Her headache symptom complex was most consistent with transformed migraine following complicated migraine (migraine with stroke).  The MEB NARSUM examination on 9 January 2006, 4 months prior to separation, noted complaints of continued daily headaches.  Physical examination showed a normal physical and neurological findings.  Diagnosis was complicated migraine with stroke and psychological factors affecting migraine and chronic daily headaches.  The commander’s statement dated 25 January 2006 noted the CI was “currently working in her primary AFSC and could perform full duties but she had numerous absences from work due to her health condition and frequent visits to the doctor.  She had been sent home on multiple occasions due to constant complaints of pain not helped by medications.  She did not work full shifts about 10% of the time.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the headache condition 30% minus an existed prior to service (EPTS) factor of 10% for a compensable rating of 20%, coded 8100 (migraine), citing chronic daily headaches when stressed that had been occurring since age 15-17.  There was no VA Compensation and Pension (C&P) evaluation in evidence.  The PEB form indicates that a 10% deduction was made for an EPTS condition, the joint disability evaluation tracking system form clearly noted the fact that the headache condition EPTS, beginning at age 15.  The Board considered the evidence as well as the natural history of migraine headaches.  By the history given by the CI to multiple examiners, she suffered from migraine headaches from age 15 until age 18.  Although she stated at the time of accession that she did not have frequent or severe headaches, she did report taking Tylenol for headaches.  The Board opined that there was evidence to support a level of disability did exist at the time of accession.  The Board majority opined that while it is clear a 10% EPTS deduction was made, the evidence does not support that level of disability at the time of accession (migraine with characteristic prostrating attacks averaging one in 2 months over last several months).  The evidence in the STR supports a rating of 0% for a history of migraine headaches with less frequent attacks.  The Board majority agreed that the CI, by all reports, was asymptomatic at accession.  Therefore, no basis for a higher EPTS deduction could be determined.  The Board then considered the migraine condition.  The PEB listed chronic daily headaches, and psychological factors affecting migraine as related diagnoses which contributed to the disability in this case.  The Board agreed that the chronic daily headaches, and psychological factors affecting migraine were diagnoses related to the migraine headaches and were not separate conditions which could be separately rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The Board assessed the PEB’s determination that the right eye visual filed loss was a residual of a severe migraine and was not separately unfitting.  This condition was not profiled, implicated in the commander’s statement or was not judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination that the residual visual field loss was not unfitting and so no additional disability rating is recommended.  The Board discussed if the migraine condition was closer to the criteria for a 50% rating, with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability, or a 30% rating, with characteristic prostrating attacks occurring on an average once a month over last several months.  The rating for a migraine condition is based on the frequency of prostrating headaches and level of economic impact.  The record shows that the CI had a total of 32 visits for an acute headache over the prior 21 months, slightly over 1-2 visits every month, but not less than once a month.  Though the CI did have documented frequent headaches there was no evidence that the migraine headaches were “completely prostrating” or had significant employment impact causing severe economic inadaptability.  The Board also observed that the comment in the commander’s statement that the CI did not work full shifts only about 10% of the time is consistent with the record where all medical appointments and instances of quarters are taken into account suggesting some work impact but not to the significant level.  The Board determined that the 50% rating was not supported.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 30% for the headache condition.  

Contended PEB Conditions: Chronic Tonsillitis and Cervical Dysplasia.  The Board’s main charge is to assess the fairness of the PEB’s determination that chronic tonsillitis and cervical dysplasia contended conditions were not unfitting.  Both conditions were not profiled, implicated in the commander’s statement or were not judged to fail retention standards.  There was no performance-based evidence from the record that the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for these two contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the migraine headache condition, the Board majority recommends a disability rating of 30%, coded 8100 IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Complicated Migraine, with Hemiplegia	8100	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150622, w/atchs
Exhibit B.  Service Treatment Record

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

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01555.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXXXXXXXXXXXXXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings 
cc:
SAF/MRBR