RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05606
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20060322

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Radar Technician, medically separated for “intractable migraine without aura” and “depressive disorder,” rated 10% and 10%, respectively with a combined disability rating of 20%.  

CI CONTENTION:  “My migraines and anxiety have gotten progressively worse since my separation.  I have had to call out of work nine times in the past year.”  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 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 - 20051220	VARD - 20061026	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Intractable Migraine without Aura	8100	10%	Migraine Headaches	8100	30%	20060719	
Depressive Disorder	9434	10%	Anxiety Disorder 	9413	10%		
Generalized Anxiety Disorder	Cat II					
Insomnia	Cat II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60% 	

ANALYSIS SUMMARY:  

Migraine Headaches.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI initially presented to headache clinic on 19 April 2005 with the report of migraine headaches since age 5 and daily headaches for as long as he could recall, although he checked no to frequent or severe headache[s] on his military entrance examination in 2000.  There had been no change in character of the migraines except increased intensity in the previous 18 months.  The pain was sometimes at full intensity when awakening.  He indicated he sought emergency care on at least 20 occasions and the STR noted treatment in clinics in September 2004 and March 2005; however an emergency department visit in January 2005 was for head trauma when he slammed his head into a dry erase board with no loss of consciousness.  At a neurology clinic visit in April 2005, he was treated for an intractable migraine with prednisone, promethazine (for nausea, zolmitriptan (to treat, but not prevent a migraine), escitalopram (an antidepressant), and zolpidem (for sleep).  At a neurology clinic visit in May 2005 his migraine headache medication was modified to sumatriptan and Depakote.  In June 2005 he was treated for a migraine and was sent by his command for “sick in quarters.”  An MRI of the brain in August 2005 showed retention cysts or polyps in the maxillary antra.  Basilar artery ectasia was noted as was a pineal region cyst.  Topiramate was added to the migraine treatment protocol on 23 August 2005.  T he was treated with intravenous metoclopramide (for nausea) and had an injection of ketorolac (a nonsteroidal anti-inflammatory drug).  

At a 27 October 2005 neurology clinic visit, he reported still having migraines almost every day despite multiple prophylactic and abortive medications.  However, he went to work every day, but left early at least one day each week.  The same-day MEB NARSUM examination, 5 months prior to separation, noted complaints of a chronic daily migraine without aura.  He described the migraine as throbbing holocephalic (entire head) pain, rated 2-10/10, which lasted up to 48 hours at its worst.  The CI reported the migraine was worsened by exertion, bright or fluorescent lights, and certain scents.  Associated symptoms included photophobia, phonophobia, nausea and vomiting, blurred vision, difficulty concentrating and fatigue and only had a few hours of fragmented sleep each night.  Medications included topiramate and sertraline.  Physical examination was within normal limits.  

At the 19 July 2006 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported migraine headaches with a severity of 8-10/10, which were marked by photosensitivity with nausea, but no vomiting.  The headaches occurred three to four times a week.  He went to bed for 6 to 8 hours, which sometimes relieved the headaches, but sometimes did not.  The neurologic component of the physical examination was normal. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the migraine condition 10%, coded 8100 (migraine), based on a 30% rating with a deduction of 20% for the migraines having existed prior to service (EPTS).  The VA rated the migraine condition 30%, coded 8100, based on the C&P examination, citing characteristic prostrating attacks occurring on an average of once a month over the last several months.  

The panel first discussed the PEB’s final rating of 10% for the migraines since it initially found the condition to warrant a rating of 30%, but deducted 20% for EPTS.  There was no clear evidence to validate the PEB’s deduction of 20%.  Also the rating options under code 8100 rely on the frequency of “prostrating” attacks; however, the VASRD §4.124a does not define prostrating.  The panel relies on the English definition of prostrating as extreme exhaustion, or powerlessness, reduced to extreme weakness.  The panel carefully considered the frequency and nature of the CI’s headaches including objective and corroborating subjective evidence.  The panel noted that the headaches at their worst lasted up to 48 hours in duration.  The non-medical assessment indicated, “He performs all assigned duties in a timely and efficient manner but multiple follow-up treatments have warranted numerous days off which is a direct result of HCP [health care problems] management and follow-up treatment.”  Therefore, by whatever route taken, the panel determined that a 30% rating for the migraine headaches was warranted.  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 migraine condition, coded 8100.  

Depressive Disorder.  According to the STR and MEB narrative summary (NARSUM), the CI presented with a 4 to 5-year history of excessive worry, insomnia, fatigue, having difficulty concentrating, and feelings of being "keyed up," and restless.  He indicated the symptoms seemed to have started about the same time that he joined the Navy.  He reported that his mind was "always going" and that he frequently had trouble quieting his thoughts enough to go to sleep.  He admitted to a history of suicidal ideation at age 16 that was connected to chronic verbal/emotional abuse by his father, but he was stopped by the thought of what his death would do to his mother and siblings.  Since that time, he did not have any further suicidal ideation, and he denied a history of homicidal ideation as well as symptoms consistent with mania or psychosis.  At a neurology clinic visit in May 2005, he was noted to exhibit anxiety symptoms that were slightly more intense than the prior month. He had been on Lexapro (escitalopram, an antidepressant) for treatment of the headaches as noted above.  Further treatment consisted of sertraline (an antidepressant) and trazadone (for sleep).  

The 2 November 2005 MEB NARSUM addendum examination, 4 months prior to separation, noted complaints of a depressive disorder.  Mental status examination (MSE) revealed the CI was alert and oriented in all spheres and was neatly groomed.  He was polite with good eye contact, but appeared uncomfortable and frequently shifted in his seat.  His mood was anxious with a congruent affect.  Thoughts were linear, logical, and goal directed.  No suicidal/homicidal ideation or audiovisual hallucinations were noted.  Insight and judgment were fair.  His Global Assessment of Functioning (GAF) score was 60 (moderate symptoms) and the level of civilian impairment was considered moderate.  

At the 27 July 2006 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported having an anxiety disorder.  MSE revealed his speech was relevant and coherent and his voice level was within normal limits.  His contact with reality was intact and he denied visual or auditory hallucinations.  Thought processes were logical and on task, and no difficulties with memory were observed.  There was no indication of obsessive ritualistic behavior or an impulse control problem.   His GAF score was 57 (moderate symptoms).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the depressive disorder 10%, coded 9434 (major depressive disorder). The PEB then made a 0% deduction for EPTS and also listed generalized anxiety disorder and insomnia as related diagnoses (Category II) contributing to the disability in this case.  The panel concluded the Category II diagnoses were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  The VA based the rating on the C&P examination, citing occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or symptoms controlled by continuous medication.  

All panel members first agreed that the preponderance of evidence did not support the application of §4.129 (mental disorders due to traumatic stress).  The higher rating of 30% requires evidence of “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” due to  such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events.”  The NARSUM, which was the only psychiatry evaluation in the STR, did not record any panic attacks, deficits in memory, or periods of inability to perform occupational tasks due to mental health symptoms.  The commander’s statement did not implicate a specific mental health condition, but noted that the CI, although not working in his source rating, was an energetic and resourceful Sailor completing all tasks assigned, which he performed in a timely and efficient manner, but had multiple follow-up treatments (presumably due to his neurological issues (migraines) since he was seen only once by a psychiatrist for the NARSUM addendum).  

Panel members agreed, the CI’s condition at the time of separation, did not support the higher 30% disability rating, and that his level of impairment was better described as occupational and social impairment due to mild or transient decrease in work efficiency and inability to perform occupational tasks only during periods of significant stress.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the depressive disorder.   
BOARD FINDINGS:  In the matter of the migraine headaches condition, the panel recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a.  In the matter of the contended depressive disorder, the panel agrees it cannot recommend it for additional disability rating. 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	
Migraine Headaches	8100	30%	
Depressive Disorder	9434	10%	
COMBINED	40%	

The following documentary evidence was considered:

 IN REPLY REFER TO 

 6040 
CORB:003 
14 May 21 
From: Director, Secretary of the Navy Council of Review Boards 
To: XXXXXXXXXXXXXXX
Subj: Physical Disability Board of Review Determination 
Ref: (a) 6040.44(Series) 

1. The Physical Disability Board of Review (PBDR) reviewed your case in accordance with reference (a) and forwarded their recommendation for action. 

2. On 23 April 2021 the Assistant Secretary of the Navy (Manpower and Reserve Affairs) accepted the PDBR’s recommendation of an increase in disability rating to 40% and placement on the Permanent Disability Retired List. This decision was then sent to Navy Personnel Command for appropriate action. 

3. The PDBR determination is final and not subject to appeal or review.