Citation Nr: 1137384 Decision Date: 10/04/11 Archive Date: 10/11/11 DOCKET NO. 09-18 665 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a compensable initial disability rating for migraine headaches. 2. Entitlement to a compensable disability rating for bruxism. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran served on active duty from February 1997 to February 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). An April 2008 rating decision granted service connection for migraine headaches and assigned a noncompensable initial rating. A notice of disagreement with the migraine headaches denial was received in September 2008. A statement of the case for the migraine headaches issue was issued in November 2008. A substantive appeal for the migraine headaches issue was received in March 2009. A January 2009 rating decision denied an increased disability rating for bruxism. A notice of disagreement with the bruxism denial was received in February 2009. A statement of the case for the bruxism issue was issued in April 2009. A substantive appeal for the bruxism issue was received in May 2009. The Board notes that there was previously some confusion concerning whether the Veteran sought to appeal the original assignment of the initial disability rating for bruxism in the June 2006 RO rating decision. In a September 2006 substantive appeal which perfected appeals of other issues, the Veteran made reference to his bruxism without clarity as to his intentions. The RO sought clarification from the Veteran in a letter sent to the Veteran in January 2007; the RO asked the Veteran to provide clarification within 6 months to indicate whether he was appealing the bruxism rating. The Veteran did not reply, and the June 2006 assignment of the initial rating for bruxism became final. Therefore, the current appeal for an increased disability rating for bruxism arises anew from the Veteran's September 2008 claim. The Board notes that the Veteran requested an opportunity to testify at a Board hearing in his May 2009 substantive appeal. The Veteran was duly scheduled for and notified of his hearing, set for May 2011. The Veteran expressly cancelled and withdrew his hearing request in signed written statements dated April 2011 and May 2011. The Board shall therefore proceed with appellate review of this case. The issue of entitlement to an increased initial disability rating for migraine headaches is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's bruxism manifests in no functional impairment due to loss of motion, no masticatory function loss, no limitation of right or left lateral excursion to less than 0 to 10 millimeters (mm), and no limitation of inter-incisal range to less than 0 to 50 mm. 2. The Veteran's bruxism does not manifest in unrestorable lost masticatory surface involving loss of all upper anterior or lower anterior teeth, nor involving the loss of all upper and lower teeth on one side. CONCLUSION OF LAW The criteria for entitlement to a compensable disability rating for the Veteran's service-connected bruxism have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7 and Diagnostic Codes 9905, 9913 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Duty to Notify The record shows that in a December 2008 VCAA letter, the appellant was informed of the information and evidence necessary to warrant entitlement to the benefits sought on appeal with regard to the issue of entitlement to an increased rating for bruxism. The appellant was also advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The United States Court of Appeals for Veterans Claims' decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. In this case, the RO provided VCAA notice to the Veteran in December 2008, which was prior to the January 2009 rating decision. Accordingly, the requirements the Court set out in Pelegrini have been satisfied. Further, the notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the appellant was provided with notice of what type of information and evidence was needed to substantiate the claim for an increased rating. Further, the December 2008 letter gave notice of the types of evidence necessary to establish a disability rating and effective date for the disability on appeal. In sum, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, VA treatment records, private treatment records, and VA examination reports. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant. The Veteran was afforded VA examinations in December 2008 and October 2009. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Board notes that the VA examination reports contain sufficiently specific clinical findings and informed discussion of the pertinent features of the Veteran's bruxism. These reports, prepared by competent medical experts and informed by direct inspection and interview of the Veteran, provide probative medical evidence concerning the features of disability applicable to the rating criteria in this case. The examination reports obtained contain sufficient information to decide the issue on appeal. See Massey v. Brown, 7 Vet.App. 204 (1994). Thus, the Board finds that a further examination is not necessary. For all the foregoing reasons, the Board concludes that VA's duties to the claimant have been fulfilled with respect to the issue on appeal decided at this time. Analysis The issue on appeal involves the Veteran's contention that a higher disability rating is warranted for his service-connected bruxism. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In the present case, it should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. The Veteran's service-connected bruxism has been rated noncompensably disabling by the RO under the provisions of Diagnostic Code 9905. Under this regulatory provision, a 10 percent rating is assigned for range of lateral excursion of 0 to 4 millimeters (mm) or for inter-incisal range of 31 to 40 mm. A 20 percent rating is assigned for inter-incisal range of 21 to 30 mm. A 30 percent rating is assigned for inter-incisal range of 11 to 20 mm. A 40 percent rating is assigned for inter-incisal range of 0 to 10 mm. 38 C.F.R. § 4.150, Diagnostic Code 9905. Ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. See Note to Diagnostic Code 9905. Consideration has also been given to the potential applicability of Diagnostic Code 9913 for tooth loss due to loss of substance of the body of the maxilla or mandible without loss of continuity. Under Diagnostic Code 9913, a noncompensable rating is assigned where the loss of masticatory surface can be restored by suitable prosthesis. Where the lost masticatory surface cannot be restored by a suitable prosthesis, a 10 percent rating is warranted for the loss of all upper anterior or lower anterior teeth, or a 10 percent rating is warranted for the loss of all upper and lower teeth on one side; a 20 percent rating is warranted for the loss of all upper and lower posterior or upper and lower anterior teeth; a 30 percent rating is warranted for the loss of all upper teeth or all lower teeth; a maximum 40 percent disability rating is warranted for the loss of all teeth. These ratings apply to bone loss through trauma or disease, such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Code 9913. The Veteran has testified, through numerous written statements and information provided to medical examiners, that his bruxism manifests in disability featuring tooth pain, wearing and loss of surface of teeth, the need to wear and replace night guards that wear out and break under the strain of his bruxism, and difficulty chewing some foods. The Veteran has not specifically testified to any particular clinical detail that meets the criteria for assignment of an increased disability rating under the applicable diagnostic codes. The Veteran was afforded a VA examination to evaluate the severity of his bruxism in connection with this appeal in October 2009. The October 2009 VA examination report documents that the examiner interviewed the Veteran regarding his symptom complaints, characterized as muscle trismus/pain bilaterally when the Veteran sleeps plus headaches associated with clenching/grinding. (The Board notes that the Veteran's headaches pathology is the subject of a separate award of disability and is addressed in the remand section of this Board decision.) The Veteran described that the discomfort was most significant when he wakes up in the morning and when he eats; the Veteran stated that he grinds his teeth in his sleep. The physical examination findings in the October 2009 VA examination report show that there was no functional impairment due to loss of motion and there was no masticatory function loss. The report also shows that the Veteran is missing only two teeth (tooth #1 and tooth #16). The inter-incisal range of motion was 0 to 50 mm. Lateral excursion was to 10 mm both to the left and to the right. The examiner indicated that there was no bone loss of the mandible, maxilla, or hard palate. The examiner found that there was no loss of teeth due to loss of substance of body of maxilla or mandible. The examiner's findings were informed by direct inspection as well as x-ray imaging. The examiner diagnosed myofascial pain dysfunction. The Veteran was also afforded a VA examination to evaluate the severity of his bruxism in connection with this appeal in December 2008. The December 2008 VA examination report documents that the examiner interviewed the Veteran regarding his symptom complaints, characterized as featuring grinding of teeth, loss of tooth surface, and difficulty eating many foods. The physical examination findings in the December 2008 VA examination report shows that functional impairment from "moderate pain on opening and closing of mouth" and "mild to moderate" masticatory functional loss. The report also shows that the Veteran is missing only two teeth (tooth #1 and tooth #16). The examiner determined that the masticatory surface could be replaced by a prosthesis. The examiner found that there was no limitation of motion of the inter-incisal range of motion. There was no bone loss of the mandible, no bone loss of the maxilla, and no bone loss of the hard palate. X-ray findings revealed no evidence of pathosis in both maxillary and mandibular arches. The examiner diagnosed chronic bruxism. The inter-incisal range of motion was 0 to 50 mm. Lateral excursion was to 10 mm both to the left and to the right. The examiner indicated that there was no bone loss of the mandible, maxilla, or hard palate. The examiner found that there was no loss of teeth due to loss of substance of body of maxilla or mandible. The examiner's findings were informed by direct inspection as well as x-ray imaging. In considering the complete medical history of the Veteran's condition, the Board notes that the Veteran was also afforded a VA examination to evaluate the severity of his bruxism in November 2005. The November 2005 VA examination report documents that the examiner interviewed the Veteran regarding his symptom complaints, characterized as "AM grinding of teeth and nocturnal bruxing.... Had masticatory myalgia secondary to bruxing tx nite splint/NSAIDS." The physical examination findings in the November 2005 VA examination report show that there was no functional impairment due to loss of motion and there was no masticatory function loss. The report also shows that the Veteran was not missing any teeth at that time. The inter-incisal range of motion was 0 to 50 mm. Lateral excursion was to 5 mm. The examiner indicated that there was no bone loss of the mandible, maxilla, or hard palate. The examiner found that there was no loss of teeth due to loss of substance of body of maxilla or mandible. The examiner's findings were informed by direct inspection as well as x-ray imaging, the results of which were within normal limits. The examiner diagnosed myofascial pain dysfunction syndrome. The Board finds that the VA examination reports of record contain sufficiently specific clinical findings and informed discussion of the pertinent features of the Veteran's bruxism. These reports, prepared by competent medical experts and informed by direct inspection and interview of the Veteran, provide probative medical evidence concerning the features of disability applicable to the rating criteria in this case. Private dental records received from a Dr. Blankenship and a dentist named J.L. Barnett show that the Veteran has been treated for bruxism. Records such as those dated in July 2004 shows that the Veteran had chipped teeth and 'severe attrition' from his bruxism, which necessitated issuing a guard to protect his teeth. However, these records do not show any findings meeting the criteria for compensable disability ratings for bruxism in this case. The Board finds that the criteria for assignment of a compensable rating for the Veteran's bruxism are not met in this case. The evidence clearly and consistently demonstrates that the Veteran has not unrestorably lost the masticatory surface for all upper or lower anterior teeth nor for all upper or lower teeth on one side; no higher rating is warranted under Diagnostic Code 9913. All of the examination reports showing the pertinent ranges of motion report that none of the ranges of motion have ever met any of the numerical criteria for a compensable disability rating. VA examination reports indicate that the Veteran either had no functional impairment due to loss of motion and no masticatory functional loss, or had some impairment due to pain but no pertinent limitation of motion. The December 2008 VA examination report indicates that there is "moderate pain on opening and closing of mouth" and "mild to moderate effect on masticatory function." However, the same December 2008 VA examination report goes on to find that there is no limitation of inter-incisal range of motion. VA examination reports before and after the December 2008 report expressly find no functional loss due to the symptoms. In light of the sum of the pertinent evidence on the topic, the Board finds that the evidence does not show that the pertinent ranges of motion meet any criteria for a compensable rating even accounting for functional loss due to pain. The Veteran's pain from bruxism is not shown in any evidence to actually manifest in limitation of the ranges of motion, nor has the Veteran specifically contended that limitation of motion occurs with the pain associated with his bruxism. The Veteran's symptom contentions have focused upon the pain he experiences from the bruxism, but have not included any indication contradicting the medical evidence showing no limitation of motion and no functional impairment of the ranges of motion due to pain. Therefore, even accounting for functional loss, the Board finds that the inter-incisal range of motion has not been limited to 40 mm or less and lateral excursion has not been limited to 4 mm or less in either direction. Therefore, no higher rating is warranted under the provisions of Diagnostic Code 9905. The Board understands the Veteran's contentions to the effect that his bruxism manifests in pain and damage to his teeth. However, even accepting this testimony, the objective medical evidence reflects that the damage to the teeth does not meet the criteria for a compensable disability rating, and the disability does not otherwise manifest in a functional limitation of motion. Consequently, the requirements for assignment of a compensable rating under applicable diagnostic criteria have not been met. In light of the above, the Board finds that a preponderance of the evidence is against the claim of entitlement to an increased initial disability rating for bruxism in this case. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Conclusion and Extraschedular Consideration In this decision, the Board has found that the evidence discussed above presents highly probative evidence with regard to evaluating the severity of the Veteran's bruxism on appeal in this case. The VA examination report specifically documents and addresses the Veteran's symptom complaints, documents the pertinent specialized clinical findings, and presents competent medical examiners' assessments of the disability informed by direct interview and inspection of the Veteran together with consideration of his account of pertinent history. The Board has reviewed the entirety of the evidence of record, including the Veteran's testimony and additional treatment records. The Board finds that none of the evidence of record probatively contradicts the findings discussed above, nor does any of the evidence of record otherwise probatively show that the criteria for any increased rating are met in this case. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severely disabling than the assigned disability rating reflects. Medical evidence is generally required to probatively address questions requiring medical expertise; lay assertions do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Board has carefully considered the Veteran's contentions and testimony. Lay testimony is competent to describe certain symptoms and experiences; the Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and is contemplated by the disability rating currently assigned. In this case, the competent medical evidence offering detailed specific findings and specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. The Board accepts the Veteran's testimony with regard to the matters it is competent to address, but relies upon the competent medical evidence with regard to the specialized evaluation of the details and clinical features of the bruxism pathology. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The preponderance of the most probative evidence does not support assignment of any increased rating in this case. Finally, in making these determinations, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence with regard to any adverse determination in this decision. The preponderance of the evidence is against finding entitlement to any increased rating in this appeal. To that extent, as the preponderance of the evidence is against the claim, the benefit-of-the- doubt doctrine does not apply and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). The Board also recognizes that the Veteran and the record refer to the impact of the service-connected disability on the Veteran's functioning, to include work functioning. In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe a veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate a veteran's level of disability and symptomatology, then either the RO or the Board must determine whether a veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, the symptoms described by the Veteran fit squarely within the criteria found in the relevant Diagnostic Codes for the disability at issue. In short, the rating criteria contemplate not only his symptoms but the severity of his disability. For these reasons, referral for extraschedular consideration is not warranted. Additionally, the Court recently held that a request for a total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate 'claim' for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue whether a TDIU is warranted as a result of that disability. Id. The Board has considered whether the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is currently sought in this appeal. In the present case, the Board finds no such question is currently raised. Indeed, the Veteran has not contended that he has been rendered unemployable by the disability on appeal; his May 2009 statement explicitly contended that his disability has caused him to miss time from work at times, which acknowledges that he has actually maintained employment and does not express unemployability. The Veteran has not otherwise expressed a contention of unemployability. Therefore, the Board finds that this appeal does not currently include an issue of entitlement to TDIU. ORDER A higher initial disability rating is not warranted for bruxism. To this extent, the appeal is denied. REMAND The Board has a well-established duty to return inadequate VA examination reports through remand to obtain adequate clarification. In this case, the Board finds that there is no adequate VA examination report of record permitting the Board to conduct fully informed appellate review of the severity of the Veteran's migraine headache pathology with regard to the applicable rating criteria. In brief, the Board notes that an essential element of the applicable rating criteria requires that the Board make findings regarding the frequency of any prostrating attacks of the headache pathology. The Veteran has submitted numerous statements of his account of experiencing severe headache symptoms. In a January 2009 statement, the Veteran described that despite taking multiple medications, including through prescriptions from his doctor, his headaches had become so painful that he could not stand exposure to light or sound, and was incapable of driving during a migraine attack. The Board believes that such descriptions raise the question of whether the Veteran experiences 'prostrating' headache symptoms and, if so, how frequently. The Veteran has subsequently repeatedly testified that he suffers from "prostrating" attacks; however, the Veteran's testimony in statements such as in February 2010 actually describe that the "prostrating" attacks typically persist a "lot longer than two months." On its face, this is a substantial contention; it is not entirely clear whether the Veteran, without shown medical expertise, is able to identify the correct medical duration of a prostrating period of symptoms or is able to distinguish between a period of 'prostrating' headache and other disruptive headaches symptoms. In light of the circumstances, it appears important to obtain an adequate medical opinion from an expert to competently address the frequency and duration of any medically prostrating attacks that may result from the Veteran's headache pathology. However, the October 2009 VA examination report of record does not adequately address the pertinent medical questions. The October 2009 VA examination report offers only the impression that the Veteran suffers from "myofascial pain causing headaches" secondary to his bruxism, and then notes that the claims-file was not available for review. Confusingly, although the October 2009 VA examination report acknowledges some of the symptoms that the Veteran has reported in his testimony in this appeal, such as needing to darken his room in order to avoid exacerbating the headaches, the report also indicates that "[h]e denies any nausea or light or sound sensitivity associated with the headaches." This confusingly appears to be inconsistent with the Veteran's testimony in written statements to VA. In any event, significantly, no consideration of or reference to the question of the frequency of any prostrating attacks is contained in this report. As the October 2009 VA examination report of record is not adequate to permit proper informed appellate review of this issue of entitlement to a compensable initial disability rating for migraine headaches, the Board must remand to develop an adequate VA examination report addressing the essential medical questions in this case. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be scheduled for an appropriate VA medical examination to ascertain the severity of his service-connected headache pathology. It is imperative that the claims file be made available to the examiner for review in connection with the examination. All indicated studies, tests, and evaluations deemed necessary by the examiner should be performed. All results of any such studies, tests, or evaluations must be included in the examination report. After examining the Veteran and reviewing the claims-file, the following questions should be addressed: (a) Does the Veteran currently have very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability? Has there been any period of time since June 2005 during which the Veteran has had such symptoms and frequency? (b) Does the Veteran currently have characteristic prostrating attacks occurring on an average once a month over the last several months? Has there been any period of time since June 2005 during which the Veteran has had such symptoms and frequency? (c) Does the Veteran currently have characteristic prostrating attacks averaging one in 2 months over the last several months? Has there been any period of time since June 2005 during which the Veteran has had such symptoms and frequency? (d) Does the Veteran currently have less frequent attacks than described in items (a), (b), and (c) above? The examiner should comment on whether or the extent to which this disability impacts the Veteran's occupational functioning. The examiner should provide a complete rationale for all conclusions reached. 2. In the interest of avoiding future remand, the RO/AMC should then review the examination report to ensure that the above questions have been clearly answered and a rationale furnished for all opinions. If not, appropriate action should be taken to remedy any such deficiencies in the examination report. 3. Following completion of the above, and any other necessary development, the issue remaining on appeal should be readjudicated. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided with a supplemental statement of the case and afforded the appropriate opportunity to respond thereto. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs