RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX                	CASE:  PD1201011
BRANCH OF SERVICE:  MARINE CORPS               	BOARD DATE:  20140129
Separation Date:  20031031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (0151/Personnel & Administration) medically separated for posttraumatic headaches.  His headaches began after a motor vehicle accident (MVA) in December 2001 and progressively got worse until they were daily headaches.  The headache condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The headache conditions, characterized as “posttraumatic headaches” and “asymptomatic Arnold-Chiari I malformation,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The PEB adjudicated “posttraumatic headaches” as unfitting, rated 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be Category III (not separately unfitting and does not contribute to the unfitting condition).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Post Traumatic Headaches (diagnosed as Migraine Headaches); Arnold Chiari Malformation (aggravated by military service); Med Board; VA C&P Exam. Columbia Neurological Assoc.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting headache condition is addressed below.  The requested Arnold Chiari Malformation condition, which was determined to be not unfitting by the PEB, is likewise addressed below.  Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Naval Records.

RATING COMPARISON:

Service IPEB – Dated 20030501	VA - (6 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Traumatic Headaches	8045-9304	10%	Cervical Disc Disease w/ Headaches Secondary to MVA Whiplash Injury	5242	10%	20040415	
Asymptomatic Arnold-Chiari I Malformation	CAT III	Arnold-Chiari Defect	8099-8021	NSC*	20040427	
No Additional MEB/PEB Entries	Other x6	20040427	
Combined:  10%	Combined:  50%	
*VA rating decision (VARD) 20041208 added Post Traumatic Headaches secondary to MVA coded 8045 rated 10% from 20031101; VARD 20080516 changed 8045 to 8045-8100, migraine headaches, and increased rating to 30%; VARD 20130930 increased rating to 50% effective 20130301.

ANALYSIS SUMMARY:  The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force.  While the DES considers all of the service member's medical conditions, compensation can only be offered for those medical conditions that cut short a service member’s career, and then only to the degree of severity present at the time of final disposition.  However, the Department of Veteran Affairs, operating under a different set of laws (Title 38, United States Code) is empowered to compensate service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should his degree of impairment vary over time.

Posttraumatic Headaches Condition.  The CI was evaluated in the emergency room (ER) for neck and back injuries sustained in a MVA when his vehicle was hit from the rear.  The examiner documented neck discomfort however no immediate headaches.  The CI was referred to a chiropractor for neck pain with headaches “all the time” and was noted to be taking a non-steroidal anti-inflammatory drug (NSAID) (Motrin).  The chiropractor continued to document that the headaches were getting worse from the whiplash injury.  The CI was evaluated by primary care who noted chronic headaches and diplopia (double vision), physical exam findings of dysconjugate gaze (failure of the eyes to turn together in the same direction) and initiated Depakote Extended Release medication for treatment.  The neurologist indicated that the CI continued to have severe headaches and a brain magnetic resonance image scan showed suggestion of  Arnold-Chiari Type I malformation (a mild malformation of the lower parts of the brain).  Evoked Potential Study (measure the electrical activity of the brain in response to stimulation of specific sensory nerve pathways) was normal.  The MEB exam for a second period LIMDU (first LIMDU period over 2 years earlier was due to an unrelated left ulnar nerve surgery) documented that the CI’s chronic occipital headache was unresponsive to codeine and Flexeril and was exacerbated by strenuous exercise.  The examiner opined that his prognosis was unknown and due to the chronic headaches which precluded him from full duty status, he should be placed on an 8-month LIMDU status.  The CI was evaluated by a civilian neurologist who noted that neurosurgery was not indicated for the Arnold-Chiari defect and further opined that the mild posttraumatic headaches were not unusual following accidents.  The MEB narrative summary exam completed approximately 9 months prior to separation documented chronic daily posttraumatic occipital and frontal headaches which were worsened by exercise and position change, along with occasional double vision; a Depakote taper was recommended and then a trial of Pamelor.  An undated neurology MEB Addendum noted that the CI was unable to perform fitness training because it worsened his headaches.  The non-medical assessment noted that the CI’s current medical conditions did not hinder his ability to perform his administrative functions and did not experience any headaches once he started on medication.  He further noted that the CI was participating in exercises at his own pace and “on the road to recovery.”  The CI was seen by a family practice clinician who noted current daily headaches for 2 weeks with symptoms of dull aching and pressure that radiated from the neck to the back of the skull along with intermittent headaches for 2 years.  The CI required ER care in June 2003 for worsening of headaches and symptoms of nausea, lightheadedness, throbbing pain in front and dull pain in back.  The examiner ordered anti-nausea injectable medication and follow up with neurology along with 24 hours Quarters for a “migraine headache.”  Two days later the neurologist noted that the constant headaches had gradually increased in severity with headache pain measured at baseline was 5-6/10 with 10 being the worst.  The pain was primarily bi-temporal, with severe prostrating pain 1 to 2 times per week, increased in severity mainly after exercise and was exacerbated by heat and exercise would cause nausea.  The civilian neurology nurse practitioner indicated that the CI had headaches daily in the bilateral occipital (back of the head) region for about 16 months, they were with him upon awakening, throughout the day and at bedtime and would increase in intensity with exercise.  The examiner added Zonegran to see if this would diminish his headaches.  The CI was seen in follow-up for posttraumatic headaches that continued to worsen with exercise.  The CI was seen by the Army neurologist who noted severe throbbing occipital headaches for 3 weeks, only relieved by sleep and exacerbated by exercise.  The examiner diagnosed posttraumatic, chronic daily headaches improved with Gabapentin; however, exercise provoked throbbing severe headaches.  The civilian neurologist documented that medications for migraine treatment were ineffective and he opined that the most likely etiology was indeed Arnold Chiari malformation; he also suggested a second opinion at a large university hospital.  The VA Compensation and Pension (C&P) exam performed approximately 5 months after separation indicated that he still had fairly constant headache pain almost every day, but he did not stay home because he was new on his civilian position.  The civilian neurologist continued to document chronic daily constant headaches and recommended a referral to pain management for nerve blocks.  The CI was evaluated by a neurologist at the VA medical center who documented constant headaches with a dull burning pain in the occipital region which would escalate to a throbbing pain.  The examiner further noted that although there was an Arnold Chiari malformation, this was minimal and the examiner was unclear as to why the headaches continued to persist.  He further suggested that he would possibly refer the CI to the VA pain clinic for further evaluation.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded posttraumatic headaches as 8045 (residuals of traumatic brain injury [TBI]) with 9304 (dementia due to head trauma), rated at 10%.  The VA coded the cervical disc disease with headaches secondary to MVA whiplash injury as 5242 (degenerative arthritis of the spine) rated at 10%.  The 8 December 2004 VARD added posttraumatic headaches secondary to MVA coded 8045, rated 10% from 1 November 2003.  The 16 May 2008 VARD changed the code to 8045-8100 (migraine headaches)  and increased the rating to 30%.  The 30 September 2013 VARD increased the rating to 50% effective 1 March 2013.  The Board reviewed the table entitled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” facets of TBI related to cognitive impairment and subjective symptoms.  The pertinent TBI rating criteria for this case are copied below for the reader’s convenience:

Facets of cognitive impairment and other residuals of TBI not Level of otherwise classified impairment Criteria:

Subjective symptoms – 0: Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family, or other close relationships.  Examples are: mild or occasional headaches, mild anxiety.

                                          - 1: Three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships.  Examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light.

                                         - 2: Three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or work, family, or other close relationships.  Examples of findings that might be seen at this level of impairment are: marked fatigability, blurred or double vision, headaches requiring rest periods during most days.

The criterion for rating TBI residuals is: “Assign a 100-percent evaluation if “total” is the level of evaluation for one or more facets.  If no facet is evaluated as “total,” assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent.”  The CI’s chronic daily headaches were well documented throughout the service treatment record.  His headaches resulted only in interference with his work and he did not require rest periods during most days as required for the “2” or 40% rating level.  The Board members agree that the impairment due to his daily headaches most closely approximated the “1” or 10% level under the TBI rating criteria.  The Board also considered the rating criteria for migraine headaches, VASRD code 8100, which is traditionally used to rate all types headaches under the analogous coding option within the VASRD.  Under VASRD code 8100, rating criteria are based on the frequency of “prostrating attacks” and are copied below: 

8100 Migraine:
With very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability ........... 50
With characteristic prostrating attacks occurring on an average once a month over last several months .................... 30
With characteristic prostrating attacks averaging one in 2 months over last several months .. 10
With less frequent attacks ................................... 0

Four months prior to separation, there is one neurologist’s note that states “pain is severe, prostrating 1-2x/wk” otherwise there is no supporting documentation (ER visits, quarters slips or duty limiting absences) of these prostrating attacks.  His commander’s non-medical assessment (completed 7 months prior to separation) stated “he is once again participating in physical exercise (at his own pace) and is on the road to recovery.”  While it is clear that the CI had daily headaches, service treatment records do not support that the CI had prostrating attacks that occurred an average of once a month over the last several months as required for the 30% rating level.  Board members agree that the CI’s daily headaches most closely approximated the 10% rating level under VASRD code 8100.  There is no reasonable rating option that would result in a rating greater than 10% for the CI’s headaches.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the Post Traumatic Headaches condition.

Contended PEB Condition.  The Arnold-Chiari Type I Malformation (A-C M) was adjudicated as a Category III condition (conditions that are not separately unfitting and do not contribute to the unfitting condition) was discussed above with the posttraumatic headaches condition.  This malformation is primarily congenital in nature (most are born with it) although Type I malformations can be acquired.  It is uncertain if the CI’s Type I malformation was congenital or acquired, but that is of no consequence as the rating would be based on the residual symptoms.  The majority of A-C Ms are asymptomatic in nature and are most commonly an incidental finding when a brain is imaged in the evaluation of another condition.  Symptomatic A-C M can cause headache (especially exercised induced), neck pain, dizziness, numbness and tingling of the hand and feet, vision problems (blurred or double vision) among other symptoms.  At one time or another, the CI experienced these subjective symptoms which could all be attributable to his A-C M.  Rating considerations for the CI’s A-C M would overlap with the rating considerations noted in the chronic headache section above and violate VASRD 4.14, (avoidance of pyramiding [evaluation of the same disability under various diagnoses]).  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB Category III determination for the asymptomatic Arnold-Chiari I Malformation contended condition and so no additional disability rating is recommended.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the posttraumatic headaches condition and IAW VASRD §4.124, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended asymptomatic Arnold-Chiari I Malformation condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.
RECOMMENDATION:  The Board, therefore, recommends that there be no-recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION	VASRD CODE	RATING	
Post Traumatic Headaches	8045-9304	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120612, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	
	XXXXXXXXXXXXXXXXXX
	President
	Physical Disability Board of Review

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 9 Apr 14

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their respective forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXXXXX, former USMC, XXX XX XXXX

						  XXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
	(Manpower & Reserve Affairs)