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Rakkasan

PTSD Does Not Cause Migraines

Question

So I received the notes today from my migraine C&P. Under the remarks at the end he says that my migraines are less likely as not due to or the result of PTSD. His rational is: PTSD does not cause tension headache or migraine headache. Also states that "He is not on any medication for headache." I am prescribed Sumatriptan by the VA!

 

I know several people who have migraines secondary to PTSD but the real kicker is that I am not claiming migraines to PTSD. I am claiming secondary to anxiety. I even had a nexus written by my neurologist stating that my migraines are connected to my anxiety. I am not for sure the C&P examiner had access to my nexus that I submitted. Am I screwed?

Edited by Rakkasan

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1 hour ago, Grumpbox said:

It looks like someone finally saw the error.  Hopefully, they will reevaluate their decision for your rating/amount of percentage.  

I noticed there was only one page here.....it was page 9 of 9??  Where is your entire addendum? This might shed more light on a rating??

 

I am also attaching the DBQ and nexus my neurologist filled out before I had my C&P. The addendum was added at the bottom of the over the phone C&P. Here it is altogether:

 

*** MEDICAL C&P EXAM MA Has ADDENDA ***

Headaches (including Migraine Headaches) Disability Benefits Questionnaire

Name of patient/Veteran: Rxxx Sxxxxx Txxxxx

Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination

Request?
[X] Yes [ ] No

ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete this

document:

[X] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a

Txxxxxxx, Rxxx Sxxxxxxxxx CONFIDENTIAL Page 24 of 48

telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence.

Evidence Review
---------------
Evidence reviewed (check all that apply):

[X] VA e-folder (VBMS or Virtual VA) [X] CPRS

1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a headache condition?
[X] Yes [ ] No

[X] Migraine including migraine variants
ICD code: R51 Date of diagnosis: 2010

[X] Tension
ICD code: G44.209 Date of diagnosis: 2010

2. Medical History
------------------
a. Describe the history (including onset and course) of the Veteran's

headache conditions (brief summary):
The veteran served in the Army from 25 May 2004 to 25 May 2012. Hserved in Iraq 2 tours 2005 to 2006 and 2007 to 2008, total of 28 months.

Hx from the veteran by phone on 7 May 2018:
Stated his headache started about 7 or 8 years ago.
He was seen at Marion VA Hospital on 31 Oct 2017 for headache,

CT head and CT sinuses was done both were negative for disease. He is not on any medication for headache.

Hx from C&P exam of 17 Nov 2017:
Veteran is claiming disability pattern for headaches, migraines. Medical opinion is requested. Veteran reports that he had headaches
start while in service in approximately 2010 after his second deployment
to Iraq. Reports that he did not seek medical care for his headaches
while in the service. Reports that he has sporadic headaches with
migraines about 2 times a month. Reports that he treats his migraines
with Excedrin Migraine as needed. Reports that his typical

Txxxxxx, Rxxx Sxxxxx CONFIDENTIAL Page 25 of 48

migraine
will last about 3 hours- reports that he will have to go into a
dark
room and lay down with a washcloth on his head. Reports that he is not
able to complete his normal day to day activities during
migraine-
reports that he has missed work or had to leave work early- reports that
he is sensitive to light and has blurry vision and unable to concentrate
due to the headache pain. Reports that over the past year he
has had to
leave work about 2-3 times a month related to his migraine headaches.

b. Does the Veteran's treatment plan include taking medication for the diagnosed condition?
[X] Yes [ ] No

If yes, describe treatment (list only those medications used for the diagnosed condition):

Over counter medication.

3. Symptoms
-----------
a. Does the Veteran experience headache pain?

[X] Yes [ ] No

[X] Pain on both sides of the head
b. Does the Veteran experience non-headache symptoms associated with

headaches? (including symptoms associated with an aura prior to headache pain)
[X] Yes [ ] No
[X] Nausea

[X] Sensitivity to light

[X] Sensitivity to sound
c. Indicate duration of typical head pain

[X] Less than 1 day
d. Indicate location of typical head pain

[X] Both sides of head

4. Prostrating attacks of headache pain
---------------------------------------
a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating

attacks of migraine / non-migraine headache pain? [ ] Yes [X] No

5. Other pertinent physical findings, complications, conditions, signs, symptoms and scars

-----------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs or symptoms related to any conditions

Txxxxxx, Rxxx Sxxxxx CONFIDENTIAL Page 26 of 48

listed in the Diagnosis Section above? [ ] Yes [X] No

b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above?
[ ] Yes [X] No

c. Comments, if any:
No response provided.

6. Diagnostic testing
---------------------
Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No

If yes, provide type of test or procedure, date and results (brief summary):

CT head and CT sinuses on 6 Nov 2017: Reported negative except Deviated nasal septum with spurring as noted.

7. Functional impact
--------------------
Does the Veteran's headache condition impact his or her ability to

work?
[ ] Yes [X] No

8. Remarks, if any: -------------------

VBMS is reviewed.

Opinion is requested: The veteran's tension headache is less likely as not

(<50/50 probability) proximately due to or the result of PTSD.

Rational; PTSD does not cause tension headache or migraine headache. Suppor is medical litrature.

/es/ Hxxxxxx Oxxxxx, MD MD
Signed: 05/07/2018 16:08

Headaches+DBQ.pdf

Nexus+Letter+for+Migraines.pdf

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Do you currently receive VA Disability for Migraines? 

Or....Post Concussion Headaches, Headaches, etc?

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1 hour ago, Grumpbox said:

Do you currently receive VA Disability for Migraines? 

Or....Post Concussion Headaches, Headaches, etc?

No, I do not.

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You should, based on this DBQ.  At a minimum, there should be a 30% rating for headaches. The doctor stuck it to you though on number 7., when he said it does not preclude you from work.  If so, this would of been a 50% rating. However, he contradicts himself prior to this, because he mentions “prostrating” headaches, which is almost always 50%; plus,  you mention how you loose work over your headaches...you should of got S/C for headaches. 

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3 minutes ago, Grumpbox said:

You should, based on this DBQ.  At a minimum, there should be a 30% rating for headaches. The doctor stuck it to you though on number 7., when he said it does not preclude you from work.  If so, this would of been a 50% rating. However, he contradicts himself prior to this, because he mentions “prostrating” headaches, which is almost always 50%; plus,  you mention how you loose work over your headaches...you should of got S/C for headaches. 

Well, what makes me mad is that Human Resources submitted my leave paperwork on how much leave I had used because of it. In the C&P the examiner even states that I miss several days of work a month because of migraines but then states that it doesn’t impact my work.

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