RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXX	CASE:  PD-2016-01136
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20040128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Communications-Computer Systems Operations Craftsman, medically separated for “Post Traumatic Migraine Headaches” with a disability rating of 10%.

CI CONTENTION:  Headaches continue to affect daily activities. She also requested a review of an additional condition not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) requested.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20031202	VARD - 20040312	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Traumatic Migraine Headaches	8100	10%	Post Traumatic Migraine Headaches	8100	50%	20040409	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Post Traumatic Migraine Headaches.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s migraine headaches condition began in August 1994 after falling and hitting her head, which caused a concussion.  A CT scan in November 1994 revealed no significant abnormalities.  She was treated with multiple forms of medication for over 9 years and in July 2003 the headaches became more severe.  A neurologic evaluation on 4 September 2003 indicated the CI had a chronic daily dull headache that turned into a migraine about 3 to 4 times per week and was treated with Percocet and Zomig (zolmitriptan).  The neurologic examination was normal. The CI was also started on Topamax (topiramate).  The examiner’s impression was refractory migraine headaches with a prior history of significant head trauma.  The initial commander’s statement dated 8 September 2003 indicated the CI complained about the severity of her headaches on numerous occasions.  However, when the CI’s supervisor suggested she take the quarters offered by her doctor, the CI said, “No, I can’t because of how busy were are right now.”  The CI was told her health was more important than the job.  The CI answered, “It’s okay, I’ll make it through the day.”  The commander also documented that the CI’s work performance was not affected except for the sharpness of her decision-making process.  Since her headache medication began, the CI demonstrated hesitation in making decisions and had not always been able to clearly communicate her ideas to others.

The 1 October 2003 MEB NARSUM examination, 3 months prior to separation, noted complaints of frequent migraine headaches that increased in severity.  The headaches were aggravated by stressful situations, bright lights, dehydration, hypoglycemia, and strenuous activity.  Her warning signs included nausea, blurred vision, and photophobia (light sensitivity).  She suffered from a chronic daily headache, which progressed into a migraine.  She would have 3 to 4 migraines per week which could last for up to 48 hours.  During the migraines she experienced nausea, photophobia, nosophobia (fear of contracting a disease) [probably should have been phonophobia (fear of loud sounds)], and blurred vision.  Sometimes the CI had the sensation she was spinning.  Physical examination including neurologic evaluation was unremarkable.  The care plan was to attempt to decrease headache frequency and intensity with prophylactic medications and pain medications.  

At the 7 October 2003 neurology examination, X-rays of cervical spine and laboratory studies were reported to be normal; Zanaflex (tizanidine, a muscle relaxant) was added to the treatment protocol.  The CI was referred to plastic surgery for Botox injections (onabotulinumtoxin A, blocker of nerve activity in muscles causing decreased muscle activity), which were given on 15 December 2003 and 29 March 2004.  The second commander’s statement dated 27 October 2003 documented the commander’s respect for the CI’s efforts to remain on the job despite her ailment, which he knew she struggled with almost daily.  The CI did not let her job performance suffer.  

The CI provided a memorandum to the MEB/PEB dated 30 October 2003 where she indicated that contrary to the second commander’s statement, she had requested quarters for her migraine from 16 to 17 October 2003.  A 15 November 2003 family practice note indicated the CI got migraines if standing for long periods of time.  The CI was directed to keep a headache log from 1 June 2003 through 25 January 2004 which detailed the dates, intensity, and medications taken for her headaches.  On 11 different occasions, spread throughout this 6-month period, the CI classified her migraine headaches as “severe incapacitating” and many others were considered “severe.”  She classified the 16 October 2003 headache as “severe” when she requested quarters, and indicated she required Percocet, Zomig, and Benadryl (diphenhydramine, an antihistamine that can cause drowsiness).  At a neurology visit on 3 February 2004 the examiner indicated the CI obtained migraine headache relief with Percocet and sleep.

At the 9 April 2004 VA Compensation and Pension (C&P) general examination, 3 months after separation, the CI reported headaches, usually on her left temple, described as a stabbing and throbbing pain associated with photophobia and phonophobia.  Her headaches were usually 6/10 in severity, but could get to 10/10.  Treatment with Percocet and Zomig was reported to be good.  Physical examination was unremarkable, which included normal muscle and sensory findings.  The mental status examination showed the CI to be alert and oriented times three.  Behavior was normal and affect was appropriate.  Comprehension was normal and memory was intact.  There were no signs of tension.  She was able to do the activities of daily living, although she had not been employed since her medical discharge.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the migraine headaches condition 10%, coded 8100 (migraine), citing progressively worsening nature of the condition and the requirement to take judgment altering medications.  The VA rated the migraine condition 50%, coded 8100, based on the C&P general examination, citing “frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability.”

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 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 highest rating (50%) under 8100 requires that the prostrating attacks are very frequent and prolonged and are productive of severe economic inadaptability.  A 30% rating requires “characteristic prostrating attacks occurring on an average once a month over last several months.”

The panel carefully considered the frequency and nature of the CI’s headaches including objective evidence and corroborating subjective evidence.  The panel noted the CI suffered from a chronic daily headache which progressed into a migraine 3 to 4 times per week and could last up to 48 hours.  She was examined numerous times and prescribed multiple medications in an attempt to relieve her headaches within one year of separation.  During her migraines she experienced different combinations of nausea, photophobia, phonophobia, blurred vision and a spinning sensation.  Based on the initial commander’s performance statement, the panel agreed, the CI was in fact recommended by her doctor to take quarters, and thereby directed by her supervisor to go home during prostrating headaches.  However, due to her dedication to duty the CI was able to withstand “severe incapacitating” or prostrating migraine headaches, as recorded in her physician-directed, meticulously documented headache log, and she chose to work.  Nevertheless, she did request quarters due to her headache condition only once, the severity of which was noted in her headache log.  Furthermore, a neurologist indicated the CI headache condition improved with sleep, which is a guideline that is determinative of a prostrating attack.  

The VA C&P examination considered the CI’s migraine headaches as “frequent, completely prostrating, and prolonged attacks….”  The PEB also considered the CI’s migraine headaches as prostrating coded 8100.  The PEB cited the CI’s “medical condition is not compatible with the rigors of military service as evidenced by the progressively worsening nature of her condition and the requirement for her to take judgment-altering medications.”  Although not exactly in concert with the exhaustion referred to in the dictionary definitions of prostrating attacks, the panel determined it reasonable to conclude the CI experienced characteristic prostrating attacks occurring on an average once a month over last several months prior to separation.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the post-traumatic migraine headaches condition, coded 8100.

BOARD FINDINGS:  In the matter of the post-traumatic migraine headaches condition, the panel recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a.  There are no other conditions within the panel’s scope of review for consideration.

The panel recommends 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 the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Post Traumatic Migraine Headaches	8100	30%	

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

XXXXXXXXXX 
XXXXXXXXXX 
XXXXXXXXXX

Dear applicant:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01136.

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 (210) 565-2273 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.