RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00759
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20070514

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Trainee, medically separated for “migraine headaches” with a disability rating of 10%.  “Seizure disorder” was determined to have existed prior to service (EPTS) and was not rated.   

CI CONTENTION:  The seizure disorder should have been rated and the migraines should have been rated higher.  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 - 200070328	VARD - 20071207	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine Headaches	8100	10%	Migraine Headaches	8100	30%	20070822	
Seizure Disorder	8910	EPTS	Seizure Disorder	8199-8103	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Migraine Headaches.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s migraine headaches began in October 2006 with uncertain origin and was admitted to the hospital on 18 October 2006 after 3 days of a severe headache, which started suddenly and was associated with complete visual loss at the onset.  Computerized tomography (CT) of the head was highly suspicious for a hyperdensity in the right occipital cortex and there was a hyperdensity in the left transverse sinus suggestive of a clot in that area.  He was admitted to the Intensive Care Unit and started on heparin (an anticoagulant).  A repeat CT scan showed no abnormality.  Magnetic resonance imaging (MRI) of the brain showed no abnormalities and a magnetic resonance venogram showed no significant abnormalities.  Due to the concern about the venous sinus thrombosis, anticoagulation was continued.  He was initially treated with Depakote, which was discontinued because of a rash.  Topamax (topiramate) was prescribed and the headaches improved, except for one headache that was treated with intravenous Toradol.  History provided by the CI’s wife indicated he had at least four episodes since age 18 that were clearly convulsionsthat included turning blue, salivating with his eyes rolled back with rhythmic jerking, followed by a postictal state.  An EEG (electroencephalogram) was normal, although his symptoms did raise the “tiny” possibility that his symptoms could somehow be related to a complex partial seizure.  At the time of hospital discharge he was ambulatory; his vision was normal; and headaches were mild, but continual. 

At a neurology visit on 26 October 2006, he continued to have severe intermittent headaches treated with oral anticoagulation and Topamax, but in November 2006 he was started on Depakote and the other medications were discontinued.  The CI experienced overall improvement in his headaches post hospital discharge, but continued to report two to three headache episodes per week.  Medication modifications included addition of Midrin and propranolol (a beta blocker).  At an ophthalmology visit on 19 January 2007 the CI reported pain “behind his right eye with headache with light sensitivity,” which was the usual course of the migraine headaches he had.  He did receive Dilaudid (hydromorphone, a narcotic) in the ER earlier in the day.  Ophthalmologic examination was benign and a CT scan on 19 January 2007 was normal without evidence of ischemia or intracranial process.  

The 20 January 2007 MEB NARSUM, 4 months prior to separation, noted complaints of headaches and seizures, but the physical examination was normal and the 22 January 2007 MEB examination (recorded on DD Forms 2807-1 and 2808) showed no focal signs.  Midrin was switched to Fiorinal on 24 January 2007, but less than a week later, the CI was hospitalized from 29 January 2007 to 30 January 2007 for headaches with photophobia (light sensitivity), right-sided throbbing, blurred vision, and right-sided facial numbness.  Treatment consisted of a DHE (dihydroergotamine) infusion with intravenous Solumedrol (methylprednisolone, a steroid), and Phenergan (promethazine, an antihistamine), which resolved the headache.  

At a neurology visit on 2 February 2007, cafergot (caffeine/ergotamine, an analgesic) was continued for abortive treatment.  At a private neurology visit on 15 February 2007 the CI reported his headaches continued, but not as bad as before.  Physical examination was normal.  Depakote was continued and Lyrica and Maxalt were added.  The commander’s statement dated 9 March 2007 indicated the CI’s sick call history reflected seeing medical personnel two to three times a week for the prior 4 months.  The 2 May 2007 private neurology visit noted complaints of bad headaches and he had a witnessed convulsion the evening before just after dinner.  

At the 22 August 2007 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported recurring headaches marked by sharp stabbing pain, blurred vision and inability to function.  He had to stay in bed and was unable to do anything.  Headache attacks averaged four to five times per week and an attack lasted for 2 days.  Physical 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.  The neurological examination was otherwise unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the migraine condition 10%, coded 8100 (migraine), citing “hospitalization in October 2006 and twice in January 2007.”  The VA also used the 8100 code, but rated the migraines at 30%, based on the C&P examination, citing characteristic prostrating attacks occurring on an average of once a month over the last several months.  Review of the record supported a conclusion that, during the several months prior to separation, the CI experienced prostrating headaches, which were marked by emergency room visits and hospitalization as well as the CI reporting at the C&P examination of an inability to function and having to stay in bed, occurring on average of once per month.  A rating of 30% was therefore justified.  There was no evidence to warrant a 50% rating, which requires prostrating attacks productive of severe economic inadaptability.  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 headaches, coded 8100.  

Seizure disorder.  According to the STR and the MEB NARSUM, the CI’s seizures began as early as 2003, some 3 years prior to enlistment in the military.  His wife described a history of at least four episodes since age 18 that were clearly convulsions as noted above.  The CI was told the convulsions were related to hypoglycemia.  An EEG was done that was completely normal.  As noted above, an initial CT scan raised the possibility of a sinus vein clot, but subsequent imaging studies were clear.  The CI had no such spells while in the hospital, but did raise the tiny possibility that his symptoms could somehow be related to a complex partial seizure.   The examiner noted the CI’s most recent convulsion had been 4 months earlier and he was unable to drive for a period of at least 2 months.  The neurologist noted the CI had a recent 40 foot fall and that may very well have played a role in the etiology of his symptoms.  No spells were reported at the 6 November 2006 neurology appointment; however Depakote was prescribed, which was indicated for both migraines and seizures.  No seizures were reported at the 8 December 2006 follow-up neurology visit.  The valproic acid (Depakote) level was 71 ug/mL (normal 50-120) on 8 December 2006.  At the 9 January 2007 military neurology clinic visit the CI reported his last convulsive episode was on 16 October 2006.  Prior to that time no anticonvulsant medication was used and there was no history of staring spells.  Review of systems revealed no vertigo, motor or sensory disturbances, good coordination and no sensory disturbances started with straining.  Neurologic examination was unremarkable.  The examiner’s primary diagnosis was a seizure disorder and the Depakote level was therapeutic.  Plasma glucose was 97 mg/dL (normal < 120), valproic acid (Depakote) level was 70.1 on 9 January 2007, and urine glucose was negative on 12 January 2007.  At the 11 January 2007 neurology visit an awake and drowsy EEG study was reported to be normal.  

The 2 February 2007 neurology clinic visit there were no convulsions, fainting, or staring spells reported.  At the private neurology visit on 15 February 2007, the neurologist, piecing together the CI’s history, indicated at the duty station a Depakote level was “high,” and the CI’s dose was diminished. “He had two seizures and his headaches worsened.  Recently he ran out of medication because of a prescription error.”  The examiner’s impression was “headaches and breakthrough seizures on a lower dose of Depakote.”  The examiner recommended continuing the current dose of Depakote.  At the return neurology office visit on 2 May 2007 the CI reported a witnessed convulsion the evening before just after dinner and noted he had missed some doses of Depakote.  Physical examination was unremarkable.  The impression was a breakthrough seizure and the dose of Depakote was increased and Namenda (memantine, a cognition enhancing medication) was prescribed.  

During the 22 August 2007 C&P evaluation the CI reported the condition existed since October 2006 and over the prior 2 years he had 10 attacks in total, averaging one each month, although he kept no attack diary.  Physical examination showed normal mental and neurological examinations.  The examiner remarked the CI had unpredictable seizure occurrences and the last occurrence was 3 weeks earlier.

The PEB determined the seizure disorder existed prior to service based on the CI’s wife’s report of convulsions beginning in 2003 prior to entering military service IAW VASRD §4.121 (identification of epilepsy) as to frequency.  The panel found no evidence to indicate this was not correct.  The panel next considered whether or not there was evidence of service aggravation.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  While the CI did have seizures on active duty at the CI’s first hospital admission in October 2006, the neurologist noted the CI had a recent 40 foot fall and that may very well have played a role in the etiology of his symptoms.   However, the neurologist was not specific whether those symptoms were related to the migraine headaches or the seizures.  Furthermore, it was not until 6 November 2006 when Depakote was prescribed to treat both the headaches and seizures, which prior to service had not been treated with any anticonvulsant medications.  Therefore, the neurologist was neither specific as to whether the seizures were service aggravated nor whether there was medical evidence based upon well-established medical principles, as distinguished from personal medical opinion alone.  Furthermore, while an initial CT scan raised the possibility of a venous sinus clot, subsequent imaging did not support that finding, although the neurologist continued anticoagulant therapy for a period of time thereafter.  While the CI did have seizures in service, they were by and large controlled with the Depakote except when the dosage was reportedly low or missed.  Therefore, the seizure disorder, although diagnosed while the CI was on active duty, in essence did not exceed the natural progression of the condition, and in fact was treated in service whereas prior to service it had not been.  Lastly, there was no evidence in the record to support the convulsions were caused by hypoglycemia while the CI was in service.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded the seizure disorder was not permanently aggravated by service beyond the natural progression of the condition.  Therefore, there was insufficient cause to recommend a change in the PEB adjudication for the seizure disorder.

BOARD FINDINGS:  In the matter of the migraine headaches, the panel recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a.  In the matter of the seizure disorder and IAW VASRD §4.124a and §4.121, the panel 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 Headaches	8100	30%	
Seizure Disorder	8910	EPTS	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180004821, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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 30% 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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,					      
Enclosure