RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-06061
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090926

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an O4, Internist, medically separated for “migraine headaches” with a disability rating of 10%.    

CI CONTENTION:  In addition to the asthma and migraines, the CI requested review 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 - 20090727	VARD - 20100708	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine Headaches	8100	10%	Cervicogenic Headaches	8100	30%	20100414	
Asthma	Cat II	Asthma	6602	30%	20100414	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Migraine Headaches.  According to the service treatment record and the MEB narrative summary (NARSUM), the CI first presented to the emergency room (ER) in September 2008 for intractable headaches. A CT of the brain was normal. He was seen in clinic on 3 November 2008 for an intractable headache for 24 hours with decreased visual acuity in the right eye, and mental status changes of feeling detached from his surroundings.  He then had an acute mental status change and decompensated and was not able to demonstrate strength in his upper and lower extremities.  He was transferred to the ER for further evaluation.  An extensive workup including a CT scan of the brain, a CT angiogram, an MRI of the brain, laboratory studies and chest X-rays were normal.  However, on 13 November 2008, a neuro-ophthalmology examination on 13 November 2008 revealed mild optic nerve hypoplasia.  His condition was described as transient visual obscuration.  A repeat MRI on 19 November 2008 showed no significant interval change from the prior study.  On 21 November 2008, the CI was given samples of Treximet (sumatriptan and naproxen to treat migraines). The examiner felt the CI’s mental status change was presumably related to a possible vasovagal response to the headache pain.  At a follow-up neuro-ophthalmology appointment on 6 January 2009 it was noted that he had findings consistent with a migraine syndrome exacerbated by cervical discomfort “cervicogenic headache.”  He had a biparietal headache on 2 February 2009 accompanied by difficulty breathing and a sensation of throat tightening.  A lumbar puncture and CT scans of the chest, abdomen and pelvis were normal except for a 4 mm soft tissue nodule in the left lower lobe, which was indeterminate.  There were no clinical signs to explain the symptoms and he was discharged home after pain symptoms resolved.  The 26 February 2009 MEB NARSUM, 7 months prior to separation, noted migraine headaches moderately controlled on Imitrex (sumatriptan) and a nonsteroidal anti-inflammatory drug.  Physical examination showed the CI was alert, oriented and in no acute distress.  The examiner noted the CI’s headache frequency had not so much been the issue as much as the severity of his episodes.  At that juncture migraine prophylaxis had not been suggested, but it was a consideration in the future.

The commander’s statement dated 30 March 2009 indicated the CI had been on quarters three times (6 duty days) in the last 2 months. The CI was seen in the ER on 26 and 27 April 2009 with complaints of migraine headaches, nausea, visual halos, a feeling of tightness in the neck and slow speech.  Treatment consisted of intravenous medication for pain and nausea with improvement.  In the family practice clinic on 10 May 2009, the CI was offered migraine prophylactic medication, but the CI indicated the debilitating headaches only occurred about every 6 weeks.  The 20 May 2009 EEG recordings were normal.  During the 9 September 2009 separation physical examination, 2 weeks prior to separation, the CI was “doing OK” recently with his migraine headaches and was taking Percocet (a  combination narcotic/pain reliever) three to four times per month for exacerbations.

At a VA neurology consult on 14 January 2010, 4 months after separation, the CI reported having a total of six migraines that required ER visits between August 2008 and February 2009.  The examiner noted the CI had not needed to go to the ER since being prescribed Percocet in May 2009 by his primary care provider.  He also had Imitrex, and it helped, but not always.  The neurologic examination was within normal limits.  During the 14 April 2010 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported severe headaches in the right occipital area, nausea, vomiting, lightheadedness, neck pain, photo and phonophobia and intermittent aura that lasted 4 hours.  The headaches last until he takes something.  The CI reported one to three headache episodes per month, with headaches lasting 3 to 4 days.  At another point in the examination he indicated the “frequency q 5-6 weeks.”  He was using Imitrex as an abortive medication and Percocet for pain management, but no prophylaxis medication.  The CI noted his headaches began during a series of hepatitis B vaccinations.  Physical examination showed normal coordination, orientation, memory and speech.  Romberg’s sign was negative.  Motor function, reflexes and sensation were normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the headache condition 10%, coded 8100 (migraine).  The VA rated the headache condition 30%, also coded 8100, citing characteristic prostrating attacks occurring on an average of once a month over the last several months.  A 30% rating using code 8100 requires evidence of “characteristic prostrating attacks on the average one a month over last several months.”  While the CI had significant migraine attacks resulting in ER visits and treatment from September 2008 through February 2009 and again in April 2009, there was no evidence in the record that he had migraine headaches with characteristic prostrating attacks since being placed on Percocet and Imitrex, although his history post-separation suggests frequent headaches that lasted until he took something.  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 panel considered the evidence.  In this case the CI’s report to the VA examiners did not indicate when the migraines took place relative to separation nor was there any evidence of ER visits, bed rest or need to move to a dark room because of prostrating headaches.  Furthermore, the migraine headaches resolved when he took something (presumably the abortive medication and/or the Percocet).  The panel noted that during the several months before separation, there was insufficient evidence of “characteristic prostrating attacks occurring on an average of once a month over the last several months.”  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 migraine headaches.  

Contended PEB Condition:  Asthma.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not implicated in the commander’s statement, but was addressed in an MEB addendum.  The panel noted the asthma diagnosis was made while the CI was in the Disability Evaluation System, which as a general rule precludes a finding of unfitness.  The panel examined the CI’s sole Officer Evaluation Report and noted his performance as a physician was excellent.  Therefore, the panel concluded that the CI more than adequately performed his duties.  Furthermore, the panel also noted the CI was a medical officer.  Therefore, IAW DoDI 1332.38 E3.P3.4.2, a “medical officer in any grade shall not be determined unfit because of physical disability if the member can be expected to perform satisfactorily in an assignment appropriate to his or her grade, qualifications and experience.  Thus, the inability to perform specialized duties or the fact the member has a condition which is cause for referral to a PEB is not justification for a finding of unfitness.”  The CI was performing his duties despite having exercise induced asthma that was treatable with an inhaled bronchodilator.  The panel majority noted that while exercise induced asthma could be unfitting for some AFSCs, it was not unfitting in this case since the CI’s performance as a medical officer was satisfactory and not at variance with the aforementioned sections of DoDI 1332.38.  After due deliberation, the panel majority concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.     

BOARD FINDINGS:  In the matter of the headache condition and IAW VASRD §4.124, the panel recommends no change in the PEB adjudication.  In the matter of the contended asthma condition, the panel majority recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

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

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-06061.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.