RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXX	CASE: PD-2018-00013
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20070419

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E5, Military Police, medically separated from the Temporary Disability Retired List (TDRL) for “chronic daily headaches” with a disability rating of 10%.

CI CONTENTION: Review requested of headaches, vertigo and mefloquine toxicity as well as a review of other 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 - 20070419	VARD - 20050506	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Daily Headaches	8199-8100	10%	Migraine Headaches Associated with Malaria	8100	30%	20050322	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Chronic Daily Headaches. According to the service treatment record and the TDRL removal narrative summary (NARSUM), the CI underwent a PEB on 12 January 2005 for the diagnosis of chronic daily headaches with vestibular auras. While deployed, he took mefloquine as a malaria prophylaxis, but stopped due to nightmares and insomnia (known possible side effects). He developed a febrile illness with severe headaches and was presumptively diagnosed with malaria. He was treated with mefloquine, but developed additional problems of vertigo, tremor, anxiety, panic, cognitive dysfunction, and nightmares.  When he was found to have a toxic blood level of

mefloquine, the medication was stopped. A lumbar puncture was consistent with a herpes simplex infection and the malaria diagnosis was called into question. He was medically evacuated on 7 December 2004, at which time the mefloquine blood level was non-detectable. Nightmares and insomnia improved with an antidepressant at bedtime, but the headaches did not significantly improve. The vertigo, cognitive dysfunction and anxiety had improved, but not completely resolved.  The CI was separated and placed on TDRL on 21 February 2005.

At the 22 March 2005 VA Compensation and Pension (C&P) examination, 25 months before TDRL removal, the CI reported 2-5 migraines per month, rated at about 8/10 in intensity. He also complained of spells of vertigo and feeling off balance, but denied any falls in the last several months. He was employed full-time in the fabrication of prostheses and had patient contact. He had not missed any days of work and the migraines seemed to occur mostly on the weekends. Physical examination revealed that the CI was in no acute distress with normal motor and neurological findings.

During the 1 February 2007 TDRL removal NARSUM examination, 2 months prior to TDRL removal, the CI reported that since November 2004, the he had complete resolution of vertigo and dizziness as well as significant improvement in sleep. He continued to experience a constant daily headache, with baseline intensity at 3-4/10, described as a dull ache centered behind both eyes. He also reported experiencing more severe migraine headaches 2-3 times per month requiring treatment with Imitrex. The episodes could last for 4 hours with medication and he would “typically stop all routine activities and lie down in a dark quiet room.” He also noted that any prolonged physical exercise such as running would often trigger a migraine episode. The examiner documented normal motor, sensory, and neurologic findings with no evidence of vestibulopathy (balance/visual issues).

The panel directed attention to its rating recommendation based on the above evidence. The final PEB at TDRL removal rated the headaches 10%, analogously coded 8199-8100 (migraine) citing “more severe episodes are 2-3 times per month” but “no evidence of prostrations” as defined IAW DODI 1332.38, Para E4.12. The VA rated the headaches (migraine headaches as secondary to the service-connected disability of malaria) 30%, coded 8100, citing the VASRD criteria based on “characteristic prostrating attacks occurring on an average of once a month over the past several months.” Of note, the VA rating decision was based on the VA C&P examination on 6 May 2005 which was 3 months after being placed on TDRL and 23 months prior to final separation.

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 panel carefully considered the frequency and nature of the headaches including objective evidence and corroborating subjective evidence. At the VA examination shortly after TDRL placement, the CI reported headaches on the weekends that caused him to lie down, however, he did not miss any work days due to migraines. At two VA primary care visits, he reported that although he had headaches 2-3 times per month, Imitrex worked well. There was no evidence of emergent visits for treatment of migraine headaches during the TDRL period, and no documentation of prostrating headaches causing lost work time. Panel members agreed that resting on weekends during migraine headaches did not rise to the level of “characteristic prostrating attacks” in the absence of corroborating evidence, and review of the record did not show prostrating headaches occurring on average once per month, or more frequently, over the last several months prior to TDRL removal to support a rating higher than the 10% adjudicated by the PEB. 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 headaches.

BOARD FINDINGS: In the matter of the chronic daily headaches and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication. 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

		PD-2018-00013

AR20190010881, XXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

	PD-2018-00013