Veterans claiming migraine, tension, cluster or other headaches use this five-page public questionnaire to give VA their clinician's account of the condition. The clinician records diagnoses, history and continuous medication, pain features and associated symptoms, then how often prostrating attacks, and completely prostrating and prolonged attacks, have occurred over recent months. VA uses the form, including its work impact section, to decide service connection and a rating.
The Veteran's treating or examining clinician (MD, DO, NP, PA or other licensed clinician) completes all nine sections and signs the Section IX certification with NPI, license and specialty. The Veteran supplies the history behind attack frequency and symptoms but does not fill in the form.
The opening block asks whether the DBQ was requested by the Veteran, a third party or someone else, whether the clinician is a VA provider, whether the Veteran is regularly seen in the clinic, and whether the exam was in person, with how it was done if not. Then mark whether records were reviewed and identify them, such as service, VA or private treatment records, with the date range.
Item 1A asks whether the Veteran now has, or has ever been diagnosed with, a headache condition. If yes, item 1B checks each type that applies, with ICD code and date of diagnosis: migraine including variants, tension, cluster, another specified headache type, or up to two other diagnoses. Item 1C lists any additional headache-related diagnoses in the same format.
Item 2A is a brief summary of onset and course. Item 2B asks whether the treatment plan includes continuous medication for the diagnosed condition and, if so, describes the treatment, listing only medications used for the headache condition rather than everything the Veteran takes.
Item 3A checks the features of headache pain: constant, pulsating or throbbing, one-sided, on both sides, worse with physical activity, or other. Item 3B covers associated non-headache symptoms, including aura: nausea, vomiting, sensitivity to light or sound, visual changes such as scotoma, flashes or tunnel vision, and sensory changes such as pins and needles. Items 3C and 3D record the typical duration, under 1 day, 1 to 2 days or longer, and location.
The section opens with VA's definition of prostrating and instructs the examiner to complete both questions. Item 4A asks whether the Veteran has characteristic prostrating attacks of migraine or non-migraine pain; item 4B asks whether attacks are completely prostrating and prolonged. For each yes, check the average frequency over the last several months: less frequent, once in 2 months, once every month, or more than once per month.
Item 5A records other physical findings, complications or symptoms related to the diagnoses. Item 5B asks about scars: painful, unstable, 39 square cm or larger, or located on the head, face or neck means completing the Scars/Disfigurement questionnaire; otherwise give the location and measurements in centimeters here. Section VI notes testing is not required and records any existing significant results with test type and date.
Item 7A asks whether the headache condition affects the Veteran's ability to work and, if so, asks for a description with one or more examples. Item 8A is for remarks, and the form asks the examiner to identify the section each remark pertains to, which helps when explaining a diagnosis change or an unusual attack pattern.
The examiner certifies the information is accurate, complete and current, under a penalty statement covering willful false statements. Items 9A to 9H collect the signature, printed name and title, area of practice or specialty, date signed, phone and fax numbers, NPI, medical license number and state, and address. VA reserves the right to confirm the authenticity of every completed questionnaire.
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Headaches (Including Migraine Headaches) Disability Benefits Questionnaire
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For VA purposes, prostrating means causing extreme exhaustion, powerlessness, debilitation or incapacitation with substantial inability to engage in ordinary activities. Item 4A asks whether the Veteran has characteristic prostrating attacks, and item 4B whether attacks are completely prostrating and prolonged. The examiner answers both and gives the average frequency of each.
For each attack type, the examiner checks one average frequency over the last several months: less frequent attacks, once in 2 months, once every month, or greater than once per month. Records reviewed for the exam, such as service, VA or private treatment records, are identified with their date range in the evidence review at the start.
No. The form states that diagnostic testing is not required for this examination report. If imaging or other studies have already been completed, the examiner gives the type of test, date and a brief summary of the most recent results in item 6A.
Yes. Item 1B lists migraine including migraine variants, tension and cluster headaches, plus other headache types and other diagnoses, each with an ICD code and date of diagnosis. The prostrating attack questions in Section IV apply to both migraine and non-migraine headache pain.