RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2019-00239
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040802

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an E5, Health Service Management Apprentice, medically separated from the Temporary Disability Retired List (TDRL) for “migraine headache” with a disability rating of 10%. 

CI CONTENTION:  The PEB did not properly characterize or rate her migraine headaches. The CI also 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 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 - 20040621	VARD - 20031003	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine Headache	8100	10%	Migraine Headaches	8100	30%	20030910	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Migraine Headaches.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s migraines began in November 2001.  The March 2003 MEB NARSUM documented proximate to TDRL placement weekly migraine headaches with one day of lost work per week due to the headaches, despite extensive treatment efforts.  The CI was separated and placed on TDRL on 31 May 2003 with a 30% rating.  At the 10 September 2003 VA Compensation and Pension (C&P) examination, 11 months before TDRL removal, the CI reported migraines three to four times per week that could be as severe as 10/10.  The examiner noted the CI’s headaches appeared to be less severe than before, but still caused “considerable distress.”  Physical examination showed a normal neurological examination.  The examiner summarized, “at the present time, she continues to experience migraines although they appear to be somewhat less frequent than before.  She has learned to adjust her life to the headaches.”  He also noted the CI had “not been taking the medications for migraines on a frequent basis.  She ha[d] not been experiencing severe complications. The [CI had] light sensitivity.  The flare-ups of the migraine [did] not include weakness, fatigue or functional loss.”

The 27 May 2004 TDRL removal examination, 2 months prior to permanent separation, noted complaints of chronic daily headaches and severe migraine headaches three times a week associated with photophobia and nausea.  The CI reported missing approximately “three days of class over the past month.”  She also reported the frequency and severity of the headaches had not changed; she had been unable to see a neurologist due to “poor access.”  Abortive medications were of no benefit, but the CI was currently taking Elavil and Inderal as preventatives.  Physical examination showed the CI in no acute distress and neurological evaluation was normal.  The examiner summarized “chronic daily headaches with transformed migraines.  [CI] still with significant frequency of headaches and severity that [were] unchanged from time of MEB.  The headaches are still quite disabling at the present time.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the migraine condition 10%, coded 8100 (migraines), citing “condition has improved since being placed on the TDRL and will not likely change over the next several years.  [CI] attending classes chooses not to work.  If [CI] would avail herself of standard care treatment, her condition would improve and stabilize.”  The VA rated the migraine headaches 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.”

Panel members deliberated between recommending a 10% or 30% rating under code 8100.  Rating guidance under this code 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 majority noted that although the CI did not provide objective evidence of prostrating headaches while on the TDRL, the reported severity and frequency of headaches was consistent with that noted in the CI’s service medical record over a long period of time, despite aggressive medical treatment.  At the TDRL re-evaluation, performed by a military neurologist, the CI reported having daily headaches with severe headaches three times per week.  She also reported missing class approximately three times per month.  The TDRL neurologist stated the headaches remained disabling and there had been no change in the migraine headache condition since TDRL placement.  Despite the lack of corroborating objective evidence, the panel majority found no basis in the record to doubt the reliability of the history reported by the CI, and with consideration of reasonable doubt (VASRD §4.3), agreed the migraine headache condition at TDRL removal more nearly approximated the 30% rating criteria (characteristic prostrating attacks occurring on average once a month over the last several months, but without evidence of frequent and prolonged attacks, causing severe economic inadaptability) than the 10% criteria (prostrating attacks averaging one in 2 months over the last several months) IAW VASRD §4.7 (higher of two evaluations).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 30% for the migraine condition, coded 8100.  

BOARD FINDINGS:  In the matter of the migraine headache condition, the panel majority recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a.  The single voter for dissent submitted the appended minority opinion.  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 Headache	8100	30%	

	

Minority Opinion:  Although the CI reported having severe migraine headaches three times per week, she was in no acute distress at the TDRL re-evaluation and her neurologic examination was normal.  During the 11 months from TDRL placement, the CI had not sought to establish care with either a primary care physician or a neurologist (the CI submitted no clinical records to the MEB or PEB to review).  Despite the CI's claim that her headaches had not changed in frequency or severity, the VA examination noted "headaches appeared to be less severe than before."    The CI estimated that she missed "approximately” 3 days of class over the past month, but she never definitively stated why she missed class.  It could have been for migraines, but it also could have been for other reasons such as sick children, etc.  The minority member could find no objective evidence of prostrating headaches occurring three times per week as reported to the examining TDRL neurologist, nor was there objective evidence of characteristic prostrating attacks occurring on an average of once a month over the last several months to support a 30% rating under code 8100.  There was not a preponderance of credible evidence to overcome the PEB’s 10% rating.  Therefore, the minority voter recommends no change to the PEB’s rating.  

SAF/MRB
3351 Celmers Lane
JBA NAF Washington, MD 20762-6435

Dear XXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2019-00239.

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 not in accordance with the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept the recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 90 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married, in such a case, failure to render an election will result in automatic enrollment by law.