RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02570
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050110

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for “chronic daily headaches” with a disability rating of 0%.  

CI CONTENTION:  Review requested of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20041006	VARD - 20050526	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Daily Headaches	8199-8100	0%	Migraine Headaches	8100	10%*	20050228	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%*	
* Decision Review Officer Decision of 20060817 increased to 30% retroactive to 20050111 with combined rating to 40%.  

ANALYSIS SUMMARY:  

Chronic Daily Headaches.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI noted a gradual increase in headache frequency in 2001, leading to daily headaches of varying intensity for at least a year.  At the 12 April 2004 MEB neurology addendum examination, 9 months prior to separation, the CI related a 3-year history of headaches with a gradual increase in frequency and varying intensity, with no change in character.  She described the headaches as throbbing and right-sided with neck pain, rated at 4-8/10, and worsened by exertion and stress, but sometimes helped by sleep.  The CI missed no days of work due to incapacitation, but sometimes felt impaired.  Identified triggers included smoke, fumes, glare, and skipping meals.  The CI denied peri-menstrual exacerbation.  Associated symptoms include photophobia, phonophobia, nausea, dizziness, blurred vision, fatigue, and difficulty concentrating.  She took over-the-counter or narcotic analgesics daily, but had not tried prophylaxis treatment.  A brain MRI was normal and physical examination showed no focal neurologic deficits.  The diagnosis was chronic daily headache (transformed migraine without aura), secondary to analgesic overuse with a plan for medication changes, including analgesic taper.  The neurologist noted that although she had daily headaches for the last year, she had not missed work, was “fit for full duty neurologically,” and that “migraine will be well controlled in the coming weeks to months.”  A headache log from May 2004, 7 months prior to separation, revealed frequent headaches and fatigue with 2-3 episodes of bedrest either attributed to headaches or to fatigue.  

The 7 July 2004 MEB NARSUM, 6 months prior to separation, referenced and forwarded the above neurology assessment.  A diagnosis of analgesic rebound headache was made and treatment was initiated with extended release Depakote as a migraine prophylaxis.  At the next visit, she reported having no significant improvement in headache frequency, but some decrease in severity.  She denied adverse side effects on daily Depakote, however, the valproate level drawn that day revealed no amount of medication in her system.  The final diagnosis was “chronic daily headache is no better control but with laboratory indication of non-compliance.…”  An MRI on 21 September 2004, 4 months before separation, for follow-up of a pituitary adenoma, revealed no significant interval changes and was interpreted as normal.  

At the 28 February 2005 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported recurring migraine headaches since 1999.  The attacks were described as sharp, painful tension headaches that escalated to migraines, which required her to stay in bed and rendered her unable to do anything.  The headaches averaged once every 3 days and lasted for 30 minutes, and were currently treated with Promethazine (antihistamine for nausea), Salsalate (nonsteroidal anti-inflammatory) and Zomig (anti-migraine agent).  There was no functional impairment from the headaches, and the CI stated she missed work once a week.  On examination, she was noted to be in no acute distress, alert and oriented times three, with normal behavior.  Cranial nerve evaluation was normal as was coordination, and there were no signs of tension.  The VA record indicated the CI submitted a headache log covering July-August 2005 (source not in evidence).  

At the neurology appointment on 12 October 2005, 9 months after separation, the CI reported chronic headaches and frequent migraines, which she described as “brain throbbing,” beginning in the morning and associated with nausea, photophobia, phonophobia, occurring at least weekly.  Daily headaches involved pain across her right parietal region.  The CI was started on Pamelor (anti-depressant) early in the summer and stated she had decreased frequency from 10mg per night (mild benefit).  Neurologic examination was normal, and the neurologist increased her medication dose with a titration schedule up to 50 mg of Pamelor per night   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the headache condition 0%, analogously coded 8100 (migraine headaches), citing noncompliance, non-prostrating headaches, and a diagnosis of analgesic rebound headache; the PEB may have applied the DoDI 1332.39, para. E2.A1.4.1.4 definition of “prostrating” (must stop what he or she is doing and seek medical attention) in effect at the time.  The VA rated the headache condition 10%, coded 8100, based on the C&P examination, citing characteristic prostrating attacks averaging 1 in 2 months over the last several months.  A Decision Review Officer Decision dated 17 August 2006 increased the headache rating to 30% retroactive to the day after separation, based on the C&P examination and subsequent treatment notes and headache log citing “migraines are occurring once or twice a week but are not shown to, be prostrating.  However, it is the opinion of this decision review officer that you more nearly meet the criteria for 30 percent than for 10 percent based on the frequency of nonprostrating migraines.”  

Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months.”  Contrasted to the rescinded DoDI 1332.39 definition, VASRD §4.124a does not require seeking medical attention for an attack to be considered prostrating.  The VASRD does not further define prostrating attacks, however commonly accepted definitions include “utter physical exhaustion or helplessness.”   The panel carefully considered the frequency and nature of the CI’s headaches including objective evidence and corroborating subjective evidence, and noted that VASRD criteria do not allow decreased ratings for non-compliance.  The commander’s statement and STR portrayed recurring headaches with significant debilitation, although there was no reported missed work.  There was no STR evidence of required bedrest in the several months prior to separation; however, headache logs prior to and after separation detailed prostrating headaches.  The post-separation evidence indicated increased headaches, which were adjudged as post-separation worsening.  Review of the entirety of the record supported the conclusion that, during the several months prior to separation, the CI’s disability picture more nearly approached the 10% criteria for prostrating headaches occurring on average once every 2 months.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the headache condition, coded 8199-8100.  

BOARD FINDINGS:  In the matter of the headache condition, the panel recommends a disability rating of 10%, coded 8199-8100 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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Daily Headaches	8199-8100	10%	

The following documentary evidence was considered:  

Exhibit A.  DD Form 294, dated 20170315, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20190007579, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

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