Migraine Nexus Letter
A board-certified physician reviews your records and writes an individualized medical opinion letter connecting your migraines to service. $549 flat rate.
Every nexus letter is written and signed by a doctoral-level provider — a board-certified physician or a Doctor of Physical Therapy (DPT). When a DPT authors a letter, a board-certified physician (MD/DO) independently reviews, validates, and co-signs it, so every DPT-authored opinion carries two doctoral-level signatures.
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$149 deposit, separate from the $400 letter fee.
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There are several recognized pathways to service-connect migraines. The right approach depends on your service history and medical records.
Direct Service Connection
If your service treatment records document headaches during active duty, or you sustained a head injury, blast exposure, or concussion in service, your migraines may be directly connected to service. A formal migraine diagnosis after separation does not prevent a direct claim if symptoms began in service.
Secondary to PTSD
PTSD and migraines share neurobiological pathways, including central sensitization and serotonin dysregulation. Chronic hyperarousal and sleep disruption from PTSD independently increase migraine frequency and severity. This is one of the most well-established secondary connections. (Peskind ER et al. Psychiatr Ann. 2013)
Secondary to TBI
Post-traumatic headaches are one of the most common sequelae of traumatic brain injury. Veterans with a service-connected TBI frequently develop chronic migraines that persist long after the initial injury. The causal chain runs: in-service TBI → post-traumatic headache disorder → chronic migraines.
Secondary to Cervical Spine / Medications
Cervicogenic headaches arise from service-connected neck injuries and cervical spine conditions. Additionally, some medications prescribed for service-connected conditions cause headaches as a side effect. Both represent recognized secondary pathways to a migraine claim.
The stronger your supporting evidence, the stronger the medical opinion we can write. Here is what we look for in your records.
- ✓A formal migraine diagnosis from a healthcare provider. This can be from your primary care physician, neurologist, or VA provider.
- ✓Documented frequency and severity of your migraine attacks. A headache diary or treatment notes showing how often attacks occur and how long they last.
- ✓Evidence of prostrating attacks. This means attacks that force you to stop what you are doing and lie down. Documenting prostrating attacks is critical for ratings above 10%.
- ✓Impact on work and daily activities. Missed work days, reduced productivity, emergency room visits, or inability to perform routine tasks during an attack.
- ✓A documented connection to a service event or service-connected condition. This could be a head injury, blast exposure, TBI diagnosis, PTSD rating, or cervical spine condition.
- ✓Medical literature supporting the causal pathway between your service-connected condition and migraines. We provide this in the letter.
You do not need all six of these elements. Even two or three strong pieces of evidence can support a favorable medical opinion. Upload what you have and we will assess your case. A migraine denial is not always final. Higher-Level Review grants have risen every reporting period, to 24.2 percent in fiscal year 2025, and the VA granted 48.2 percent of supplemental claims that year; see our 2025 VA claims and appeals report.
What goes into a migraine nexus letter.
A nexus letter, formally an independent medical opinion (IMO), addresses whether your migraines are directly related to an in-service event, whether they are secondary to or aggravated by a service-connected condition, and how severe and prostrating the attacks are.
Credentials and records reviewed
The letter opens with the author’s degree, board certification and licensure, to establish credibility with the rater. It then lists the specific records reviewed: service treatment records, VA medical records with date ranges, private treatment records and anything else in the file. “I reviewed the veteran’s records,” with no specifics, is less credible and harder to defend. An opinion is only as good as its informational basis, and a rater or Board judge will look first at whether the author had the complete record.
Clinical history and current diagnosis
The letter summarizes when the migraines began, the in-service events that may have contributed, prior and current treatment, and how the condition has progressed. That anchors the opinion in your actual history rather than a generic one. It then states the current diagnosis in standard terms, such as migraine without aura, migraine with aura, chronic migraine, vestibular migraine, or post-traumatic headache with migraine features. A records-based opinion says so, and that is entirely acceptable.
The rationale
This is the most important part. A strong rationale explains the specific biological mechanism for your pathway, for example trigeminovascular sensitization after blast exposure, shared HPA-axis dysregulation for PTSD → migraine, or trigeminocervical overlap for cervical spine → migraine. It explains why the onset or chronification timeline is medically consistent, takes on likely denial arguments (medication overuse if present, gaps in the record), and references the literature without overstating it. “Migraines can be caused by PTSD” is a weak rationale. A strong one explains why this veteran’s migraines are at least as likely as not caused by this veteran’s PTSD, given the specific history, timeline and mechanism.
Severity and the legal standard
A well-built letter also gives clinical context on severity: whether the attacks described in the records are consistent with the prostrating standard under DC 8100. That is not the author rating you; it is context that supports the correct application of the rating schedule. The opinion itself applies the “at least as likely as not” standard (38 CFR 3.102) in so many words. “Possibly,” “may be related” and “cannot rule out” do not meet it and are treated as non-favorable. The letter is signed, with the author’s credentials, licensure and contact information; an unsigned or improperly attributed letter carries no weight.
What a nexus letter cannot fix
A letter supports a claim that has a factual foundation; it cannot create a relationship where none exists. It does not replace a current diagnosis in the record, evidence of the in-service event (your lay statement or service records), or frequency documentation. The letter speaks to service connection; how often the attacks happen comes from your headache diary and treatment records.
The VA rates migraines under Diagnostic Code 8100. Here are the four rating levels.
| Rating | Criteria |
|---|---|
| 50% | Very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. |
| 30% | Characteristic prostrating attacks occurring on average once a month over the last several months. |
| 10% | Characteristic prostrating attacks averaging one in 2 months over the last several months. |
| 0% | Less frequent attacks. |
Real results from real veterans.
$149 deposit; $400 per letter. If your case is not supportable, the $400 letter fee does not apply and your deposit is refunded in full.
Our secure HIPAA-compliant intake form opens in a new tab. It takes about 10 minutes. No documents needed right away — you can upload records during the process.
Open Secure Intake Form →Fully refundable $149 deposit at intake. $400 for the letter only if we can support your case.