RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-02696 
BRANCH OF SERVICE:  Army	BOARD DATE:  20150717
SEPARATION DATE:  20080528 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Military Police) medically separated for migraine headaches.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent S2 profile and referred for a Medical Evaluation Board (MEB).  The “migraine headache” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions detailed in the chart below for PEB adjudication.  The Informal PEB adjudicated “migraine” as unfitting, rated 0% likely application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  Her conditions continue to worsen and negatively impact her daily activities.  Her complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

IPEB – Dated 20080409	VA* -  Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine 	8100	0%	Migraine Headaches	8100	0%	STR	
Depression NOS (resolved and treated)	Not Unfitting 
	Chronic Psychiatric Disability to include Irritability
and Behavior Changes	9400	NSC	
Pain Disorder Associated with both Psychological Factors and a General
Medical Condition (Migraines)					
Other x 2 (Not In Scope)	Other x 5	
RATING:  0%	COMBINED RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20081030 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:   

Migraine.    The service treatment records documented a history of headaches that began in 2005 after starting Depo-Provera.  The headaches initially were bilateral, radiated to the left face, associated with occasional flashing lights; however, were not associated with nausea, vomiting, passing out or alteration in mental status.  The headaches were initially responsive to migraine medication; however, later became more severe and more frequent.  The physician recommended discontinuing the Depo-Provera and using another form of contraception.  Treatment records were silent from October 2005 until February 2007, at which time the CI presented to the neurology clinic for evaluation of headaches.  At the neurology visit, the CI recounted her history of headaches and reported her headaches were worse in the past 5 months after having marital problems.  Her headaches were usually left sided, behind her eyes and traveled to the back of her head.  Her face and arm were numb for about 8 hours.  The headache was pounding, sharp, with associated nausea, light and sound sensitivity and felt “like her eyeballs wanted to pop out.”  She reported daily headaches for the past year and was taking Topamax (headache prevention) twice a day without improvement.  The neurological examination was normal, and she was diagnosed with chronic migraine headaches.  In September 2007 the CI presented to the emergency room (ER) for a severe headache associated with blurred vision and nausea.  Her headache was treated with an injection of toradol (narcotic) medication.  The provider noted that the CI was taking abortive medication only.  Neurology clinic consultation dated 25 September 2007 documented that both preventive and abortive therapy had been prescribed for migraine treatment.  The CI was given trials with multiple medications, a few produced undesirable side effects, and at times relief was achieved via narcotic agents.  Magnetic resonance imaging of the brain in September 2007 was normal.  The MEB narrative summary dated 3 January 2008, approximately 5 months before separation, documented the CI’s headaches were managed with daily preventive medication and abortive medication.  She was being followed by neurology every 3-6 months.  The CI reported her headaches worsen with activity, and she had some degree of headache each day.  The examiner assessed migraine headaches with pain rating of slight/occasional.  The commander’s statement dated 30 October 2007, 7 months before separation, documented the CI’s headaches resulted in her being sent home at least 2 times a week.  The CI was non-attendant to the scheduled VA Compensation and Pension examination.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition 0% coded 8100 (Migraine), citing her condition as stabilized and improved with medication and headaches “are no longer prostrating, but remain frequent and severe to interfere with duty”.  The VA rated the condition at 0% based on service treatment records, coded 8100.  The 10% rating under this code requires one prostrating headache in 2 months over past several months.  The higher rating of 30% requires once monthly prostrating headaches over several months.  Key evidence of prostrating, severity, and frequency include evidence of the stoppage of work or current activity, and measures taken to alleviate the headache (time off from work, accommodations such as having to go to a darkened/quiet room), evidence of self-management (medications, sleep), treatment notes, and supervisor statement.  As noted above the commander’s statement documented that the CI’s headache resulted in having to leave work twice a week or more, and noted that she had to occasionally leave work to seek medical care from the ER; however, there was no documentation that the CI sought help and care after early dismissal from work.  Treatment records provided evidence of only one ER visit (September 2007), and absence of clinical notes beyond September 2007.   Board members agreed that the ER visit with treatment for headache, was consistent with the definition of a prostrating headache and appeared to have supported the 10% criteria.  The September 2007 neurological examination noted that the headache frequency had increased to daily over the past month without reference to impact on occupational functioning, or workplace accommodation.  With the exception of the ER visit noted above, there was no evidence of incapacitating episodes related to ER visits, and no prescribed quarters.  All Board members agreed that the 30% criteria were not supported by the evidence.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the migraine headaches condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the pain disorder associated with both psychological factors and a general medical condition (migraine) were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The condition was listed as S2 on her profile; however, there were no duty restrictions or limitation related to the above condition.  No mental health condition was implicated in the commander’s statement and none were judged to fail retention standards.  The pain condition associated with migraine headaches was reviewed and considered by the Board.   There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  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 fitness determination for the contended condition and so no additional disability rating are 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 migraine condition, the Board unanimously recommends a disability rating of 10%, coded 8100 IAW VASRD §4.124a.  In the matter of the contended pain disorder associated with both psychological factors and a general medical condition (migraine) condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Migraine	8100	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20121218, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXX, AR20150013730 (PD201302696)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXX						                                                Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA