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Migraines Secondary to PTSD


NAVY GULF WAR VET

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I'm a Gulf War Veteran. Over the years my migraines headaches have gotten worse and I recently submitted a claim for migraines secondary to PTSD since Im rated at 70% SC for PTSD and 50% SC for sleep apnea.  See my 2015 C&P exam for migraines below:

2015 Migraine C&P Exam
    
    [ ] Review of available records (without in-person or video telehealth
        examination) using the Acceptable Clinical Evidence (ACE) process 
because
        the existing medical evidence provided sufficient information on which 
to
        prepare the DBQ and such an examination will likely provide no 
additional
        relevant evidence.
    [ ] 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
        telephone interview provided sufficient information on which to prepare
        the DBQ and such an examination would likely provide no additional
        relevant evidence.
    [ ] Examination via approved video telehealth
    [X] In-person examination
    
    Evidence review
    ---------------
    Was the Veteran's VA claims file reviewed?
    [X] Yes   [ ] No
    
      If yes, list any records that were reviewed but were not included in the
      Veteran's VA claims file:
      
        VBMS
        
      If no, check all records reviewed:
      
        [ ] Military service treatment records
        [ ] Military service personnel records
        [ ] Military enlistment examination
        [ ] Military separation examination
        [ ] Military post-deployment questionnaire
        [ ] Department of Defense Form 214 Separation Documents
        [ ] Veterans Health Administration medical records (VA treatment 
records)
        [ ] Civilian medical records
        [ ] Interviews with collateral witnesses (family and others who have
            known the Veteran before and after military service)

        [ ] No records were reviewed
        [ ] Other:
              
    1. Diagnosis
    ------------
    Does the Veteran now have or has he/she ever been diagnosed with a headache
    condition?
    [X] Yes   [ ] No
    
       [X] Tension
              ICD code: ICD-9-CM 307.81      Date of diagnosis: unknown
    2. Medical History
    ------------------
    a. Describe the history (including onset and course) of the Veteran's
       headache conditions (brief summary):
         He denies any specific head injuries that precipitated headaches. He
         reports that he was diagnosed with headaches while on active duty. He
         reports that his headaches are intermittent in nature. He has a 
headache
         about every other day that is rated a "6". He takes Aleve for his
         headaches. He denies having to leave work due to his 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):
         He takes Aleve ii tabs by mouth as needed to get rid of his headache.
         
    3. Symptoms
    -----------
    a. Does the Veteran experience headache pain?
       [X] Yes   [ ] No
       [X] Pulsating or throbbing head pain
       [X] Pain localized to one side of the head
       [X] Pain worsens with physical activity
    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] Sensitivity to light
    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 
and/or
       symptoms
    
-----------------------------------------------------------------------------
    a. 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
       
    b. Does the Veteran have any other pertinent physical findings,
       complications, conditions, signs and/or symptoms related to any 
conditions
       listed in the Diagnosis section above?
       [ ] Yes   [X] No
       
    6. Diagnostic testing
    ---------------------
    Are there any other significant diagnostic test findings and/or results?
    [ ] Yes   [X] No
    
    7. Functional impact
    --------------------
    Does the Veteran's headache condition impact his or her ability to work?
    [ ] Yes   [X] No
    
        
    8. Remarks, if any:
    -------------------
       Medical Opinion; VBMS was reviewed and there was no mention on his exit paperwork that he had any problems with headaches. When the veteran came to the VA for treatment, in 2009, his PCP appt. put this statement about his headaches in the record, "NEURO-tension headaches , had CT scan of head  in the County ER and it was negative. No migraine headaches. No seizures, no stroke." The veterans current headache problems are diagnosable with a partially known etiology. This condition is less likely as not caused by or a result of his active duty service time in the Navy over 20 years ago.

_______________________________________________________________________________________________________________________________________________________________________________________________

Since 2015 my headache severity and occurrences have almost tripled.  I submitted a claim for migraines secondary to PTSD since Im rated at 70% SC for PTSD and 50% SC for sleep apnea.   I submitted case notes from my PCP stating I have migraines along with prescription meds and dr. notes from non-va neurologist who diagnosed me as well and prescribed migraine meds. In January of this year, my VA dr. started prescribing  me meds for my migraines as well since my insurance changed and visits to the neurologist were billed as out of network and was too high to pay out of pocket.  

I submitted a lay of statement from my wife, a migraine diary with 6 months of records,  and my neuro dr. notes that indicate that I missed almost 5 days per month out of the 15 scheduled days because of these headaches along with  meds prescribed for my PTSD that has side effects that cause headaches. 

Will this be enough to assist with establishing my claim?  My claim has been  in PFD for over 45 days and have exceeded the estimated time of completion twice  and no C&P exam has been scheduled or pending.  Any comments? 
       

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Based on the above I'd say you should get the 50% given for Migraines  its the highest percent a veteran can get for the headaches.

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2 hours ago, Buck52 said:

Based on the above I'd say you should get the 50% given for Migraines  its the highest percent a veteran can get for the headaches.

Thank you for responding.  What's concerning is the fact they have not schedule me for another C&P exam.  I was told C&P exams are needed for majority of VA claim cases.  My claim was scheduled to be completed on 02/22/2019. That date passed & then Ebenefits was updated on 03/22/2019 to be completed within 7  days on 03/29.   Yet it's still in PFD.  No information is needed from me or others and yet the date keeps getting pushed out.  I know the process is slow, however do you have any suggestions on what may be happening with my case and why the dtae was updated to 7 days and then still surpassed?  Just wondering!

Edited by NAVY GULF WAR VET (see edit history)
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Thank you for responding.  What's concerning is the fact they have not schedule me for another C&P exam.  I was told C&P exams are needed for majority of VA claim cases.  My claim was scheduled to be completed on 02/22/2019. That date passed & then Ebenefits was updated on 03/22/2019 to be completed within 7  days on 03/29.   Yet it's still in PFD.  No information is needed from me or others and yet the date keeps getting pushed out.  I know the process is slow, however do you have any suggestions on what may be happening with my case and why the dtae was updated to 7 days and then still surpassed?  Just wondering

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I am SC for Migraines 2nd to PTSD and am rated at 30% I believe. I had all my paperwork and DBQ filled out from my private DR. I can try to help you with this if I can. It looks tome they said 50% less likely than not so to me that means no service connection. Let me know when you get your answer if you can.

Also, I am in appeals on my SC OSA 2nd to PTSD. Were you diagnosed with OSA while in service. I don't know many that have made it where you are on that one. Any help will be appreciated

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If you show enough medical evidence and the rater reads it  & that you show enough probative medical evidence with your medical  documentations AND  show  your Headaches are related to your PTSD   sometime a C&P will not be ordered...you can still win your claim without a C&P

but they can still send you to a C&P  before a decision is made.

Edited by Buck52 (see edit history)
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Thanks. I submitted my claim for OSA about a year after I was SC 70% for PTSD.  My wife was concerned with the lack of sleep, nightmares, and everything else mentally going on with me . Later she scheduled an appointment with my  PCP who ordered me to see an ENT specialist. The ENT doctor  ordered a sleep study and I was diagnosed me with OSA. The ENT doctor completed the DBQ and provided medical facts that supported PTSD and sleep apnea relationship. I submitted my claim to the VA with all of the information  and they then ordered me to another specialist who indicated my PTSD was least likely affecting OSA.  About 6 months later the VA approved the claim and awarded OSA. 

 

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Thanks. I submitted my claim for OSA about a year after I was SC 70% for PTSD.  My wife was concerned with the lack of sleep, nightmares, and everything else mentally going on with me . Later she scheduled an appointment with my  PCP who ordered me to see an ENT specialist. The ENT doctor  ordered a sleep study and I was diagnosed me with OSA. The ENT doctor completed the DBQ and provided medical facts that supported PTSD and sleep apnea relationship. I submitted my claim to the VA with all of the information  and they then ordered me to another specialist who indicated my PTSD was least likely affecting OSA.  About 6 months later the VA approved the claim and awarded OSA. 

 

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Thanks @Buck52. I have been following this site for a while and your knowledge and advice is greatly appreciated.  So, the C&P exam listed above was from 2015. It looks like I have all the signs of the migraines, however at that time, I wasn't having them at the rate/frequency I am now.

For the recently submitted claim I filed headaches related to PTSD and migraines secondary to PTSD to cover my tracks bc the 2015 C&P exam indicated I was diagnosed with tension headaches and no migraine diagnosis on the VA level. As of March 2017 I now have a diagnosis of migraines and migraine prescriptions  from private PCP and private neurologist and within the past year my VA PCP prescribed and recorded my migraine headaches in my VA file and also prescribed Topamax and Sumatriptan as well. 

My claim has went from PFD to GOE 3 differ times within the last 6 weeks  and each time its always extended over the estimated date of completion before they keep editing and changing the dates of completion. As of yesterday I went from PFD back to gathering evidence  with a completion date around 7/29/2019 - 10/11/2019 and no C&P exam has been ordered (from what I can see)

I know ebenefits can be tricky and I have to play the waiting game like every other vet, but has anyone every went through this for migraine claim with dates constantly changing and being prolonged for FULLY DEVELOPED CLAIM. 

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