RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00316
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040913

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “migraine headaches” and “focal seizures,” rated at 10% each, with a combined disability rating of 20%.

CI CONTENTION:  The CI made no specific contention.  The 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 Board 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 determination 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(s) 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 - 20040623	VARD - 20130423	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine Headaches…	8045-9304	10%	Capitalize Each Word	8100	0%	20130416	
Focal Seizures…	8912	10%	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Migraine HA.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s migraine condition began after a motor vehicle accident in November 2001 with head injury and loss of consciousness (LOC) for several minutes.  He was hospitalized for observation and immediately began having headaches (HAs).  The CI denied a history of HAs prior to the head trauma but afterword he experienced daily migraine HAs associated with visual changes and sensitivity to light and sound.  The CI was deployed in January 2003 and experienced a second head injury when the driver’s hatch of the tank fell on his head.  He did not have LOC or any other symptoms immediately except HAs.  The 19 August 2003 neurology evaluation diagnosed migraines and cervicogenic HAs as well as occasional complex partial seizures with secondary generalization (see seizure condition below).  The CI had been tried on multiple migraine medications without significant benefit and his medications were changed to a muscle relaxant and an anticonvulsant medication (Depakote).  At the 10 November 2003 neurology follow-up visit, the CI reported the severity and frequency of his HAs had improved on the Depakote.  

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 20 January 2004, 8 months prior to separation, the MEB examiner noted the CI had been to the ER for HAs 4-5 times in the past 6 months.  The MEB NARSUM examination on 20 January 2004, 8 months prior to separation, noted complaints of daily HAs with sensitivity to light and visual aura.  He reported that twice a week he was sent home due to HA and he took medication and rested with the lights out.  Physical examination was normal.  The NARSUM noted magnetic resonance imaging was performed during the CI’s evaluations and was negative for brain abnormalities.  A 30 January 2004 primary care visit for the MEB noted the CI had to leave work approximately two times per week due to migraine HA.  At a 25 February 2004 emergency room visit the CI was treated for severe HA with vomiting and photophobia.  At an 11 March 2004 neurology visit for a MEB opinion, the CI reported migraine HAs every 3 days on Depakote.  Additional medications for migraine prevention and migraine treatment were prescribed and continuation of the MEB was recommended.  There was no VA Compensation and Pension examination performed proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the HA condition 10%, analogously coded 8045-9304 (dementia due to head trauma), citing a neurological evaluation dated 12 March 2004.  The CI developed migraine HAs following head injury and VASRD code 8045 indicates that purely neurological disabilities will be rated according to the applicable VASRD code with a hyphenated code of 8045-XXXX.  The PEB rated the migraines HAs under 8045-9304, with a maximum rating of 10%, which the VASRD in effect at the time of separation indicated was to be used for “purely subjective complaints such as headaches, dizziness, insomnia, etc.”  The CI was diagnosed by multiple neurologists with migraine HAs, a neurological diagnosis, and the HAs were associated with light and sound sensitivity, visual changes, nausea and vomiting.  The CI was treated in the ER on multiple occasions for severe migraine HAs with associated symptoms.  The panel judged that the migraine HAs could not be characterized as “purely subjective” as some non-specific type HAs may be (such as HAs related to muscle tension or fatigue) and should be appropriately rated under 8045-8100 (migraine headaches).  

The MEB NARSUM examination noted the CI needed to leave work approximately twice per week due to a migraine HA and the MEB Form 2808 examiner noted the CI had been seen in the ER 4-5 times in the last 6 months, which both support the 30% rating for “characteristic prostrating attacks occurring on average once per month over the last several months.”  However, there was no evidence to support that the migraine attacks were “completely prostrating and prolonged” and “productive of severe economic inadaptability” to warrant higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the migraine HA condition, coded 8045-8100.  

Focal Seizures with Secondary Generalization.  According to the STR and the MEB NARSUM, the CI’s seizure condition began after the first head injury in November 2001 noted above.  The CI was deployed and on 6 May 2003 reported a second head injury due the driver’s hatch of a tank falling on his head, without LOC or other symptoms except HA, as noted above.  The day after the injury the CI experienced a witnessed seizure, without loss of bowel or bladder control or tongue biting.  The CI had 4-5 seizures before being medically evacuated and one seizure involved loss of bladder control.  The 21 May 2003 primary care evaluation noted the CI self-reported episodes of altered mental status and arm/leg movements.  He denied any history of epilepsy prior to enlistment.  The examination note indicated there had been two witnessed seizures since the original head injury, but the CI had not undergone evaluation for seizures.  The CI was medically evacuated due to uncontrolled migraine HAs and further evaluation of the seizure symptoms.  At the 19 August 2003 neurology evaluation, the CI reported severe HAs several times per month and at least three episodes of LOC with involuntary movements lasting several minutes.  The neurologist diagnosed migraine HAs and complex partial seizures with secondary generalization and anticonvulsant medication (Depakote) was started.  At the 10 November 2003 neurology follow-up visit, 10 months before separation, the CI reported a recent migraine with his typical throbbing pain, nausea, vomiting, and photophobia, however, he lost consciousness and generalized tonic-clonic activity was witnessed, with confusion and lethargy present after the episode.  He reported that he had not had other seizure like activity in the recent past.  The neurologist indicated Depakote was a good choice of medication for both the migraines and the focal seizures and the dosage, which was relatively low, was increased.  

At the MEB examination the MEB examiner noted there had been one seizure since return from deployment in May 2003.  The MEB NARSUM examination noted there were no further seizures since November 2003, after the CI was titrated to a therapeutic dose of Depakote.  Physical examination was normal.  The 11 March 2004 neurology visit for a MEB opinion also noted there had been no further seizures since on Depakote.  The NARSUM indicated that the Service neurologist agreed with the diagnosis of both migraines and seizures and recommended that the MEB be continued.  An electroencephalogram performed on 25 March 2004 was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the seizures condition 10%, coded 8912 (epilepsy, Jacksonian and focal motor or sensory), citing seizures controlled with medication.  The evidence in record supports that the CI did not experience partial or major seizure activity in the 10 months before separation once titrated to a sufficient dose of anticonvulsant medication.  Therefore, although the CI did experience a single witnessed major seizure in the year before separation, the panel concluded that the prompt control achieved with the first medication the CI was prescribed after having a neurology evaluation and diagnosis supports the PEB 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the seizure condition.  

BOARD FINDINGS:  In the matter of the migraine condition, the panel unanimously recommends a disability rating of 30%, coded 8045-8100 IAW VASRD §4.124a.  In the matter of the focal seizures condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Migraine HA	8045-8100	30%	
Seizures	8912	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160523, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015268, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 40% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure