Citation Nr: 1342541 Decision Date: 12/23/13 Archive Date: 12/31/13 DOCKET NO. 10-09 277 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a compensable evaluation for urticaria prior to May 1, 2013. 2. Entitlement to an evaluation higher than 10 percent for urticaria since May 1, 2013. 3. Entitlement to a compensable evaluation for mixed tension and migraine headaches prior to May 1, 2013. 4. Entitlement to an evaluation higher than 30 percent for mixed tension and migraine headaches since May 1, 2013. 5. Entitlement to an evaluation higher than 20 percent for lumbosacral strain since. REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD T. S. Willie, Counsel INTRODUCTION The Veteran served on active duty from August 1998 to April 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board notes that it has reviewed the Virtual VA and VBMS paperless claims processing systems and has included evidence pertinent to the appeal in the decision therein. Initially, the Board notes that although the Veteran is unemployed, she has not asserted, and the evidence does not suggest, that that she is unemployable as a result of her service-connected disabilities. Rather, it is indicated in the record that she is home taking care of her minor child. Accordingly, a claim for a total disability rating based on individual unemployability (TDIU) is not inferred nor addressed herein. Rice v. Shinseki, 22 Vet. App. 447 (2009). FINDINGS OF FACT 1. Throughout the appeal period, urticaria was manifested by recurrent episodes of urticaria occurring at least four times during the past 12-month period, and responding to treatment with antihistamines or sympathomimetics, but was not manifested by recurrent debilitating episodes occurring at least four times during the past 12-month period, requiring intermittent systemic immunosuppressive therapy for control. 2. Throughout the appeal period, mixed tension and migraine headaches were manifested by characteristic prostrating attacks occurring on an average of once a month over the last several months but were not manifested by prolonged attacks productive of severe economic inadaptability. 3. Lumbosacral strain is manifested by the functional equivalent of flexion of the lumbar spine greater than 30 degrees. CONCLUSIONS OF LAW 1. Throughout the appeal period, the criteria for a 10 percent rating, but no more, for urticaria are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2013); 38 C.F.R. § 4.118, Diagnostic Code 7825 (2013). 2. Throughout the appeal period, the criteria for a 30 percent rating, but no more, for mixed tension and migraine headaches were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.124a, Diagnostic Code 8100. 3. The criteria for a rating higher than 20 percent for lumbosacral strain are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met with regard to the issues decided herein. There is no issue as to providing an appropriate application or the completeness of the application. By correspondence dated in April 2008, and prior to initial adjudication, VA advised the Veteran of the information and evidence needed to substantiate the claim. The document provided notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. The Veteran was also provided information regarding the assignment of disability ratings and effective dates. VA has also satisfied its duty to assist. The claims folder contains service treatment records, VA medical records, VA examinations and identified private medical records. No additional pertinent records are shown to be available, and the Veteran does not argue otherwise. Additionally, the examinations are adequate because they contain a history obtained from the Veteran and thorough skin, headache, and back examinations relevant to the applicable rating criteria. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim. No further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). Accordingly, the Board will address the merits of the claims. This appeal was remanded by the Board in February 2013. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a Court or Board remand confers upon the appellant the right to compliance with that order). That remand requested medical records be obtained and current examinations be provided. Those records have been associated with the claims file and examinations were provided in 2013. Accordingly, the Board finds that there has been substantial compliance with its previous remand and it may proceed to adjudication of this appeal. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). Increased evaluation criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 , 4.2 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 . Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.) A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Urticaria The Veteran appeals the denial of a compensable evaluation for urticaria from March 24, 2008 to May 1, 2013 and a 10 percent rating thereafter. The Veteran's disability is rated under Diagnostic Code 7825. Under Code 7825, a 10 percent rating is warranted where there are recurrent episodes of urticaria occurring at least four times during the past 12-month period, and; responding to treatment with antihistamines or sympathomimetics. A 30 percent rating is warranted where there are recurrent debilitating episodes occurring at least four times during the past 12-month period, requiring intermittent systemic immunosuppressive therapy for control. A maximum 60 percent evaluation is warranted where there are recurrent debilitating episodes occurring at least four times during the past 12-month period despite continuous immunosuppressive therapy. 38 C.F.R. § 4.118. A review of the record discloses that a 10 percent evaluation for urticaria prior to May 1, 2013 is warranted. In March 2008, Veteran reported urticaria when hot, and she was directed to avoid sun light and heat. The Veteran did not have hives on that day. In April 2008, she was seen for problems with her skin. She described her skin as very itchy and blistering when exposed to heat even with regular clothes on. In the May 2008 VA examination, her disability was described as intermittent and progressive. She used loratadine, an antihistamine, to help with the rash when exposed to the sun. She also used camphor/menthol lotion and sunscreen. Local symptoms included burning sensation and itching. She did not have any urticaria lesions at that time or scarring. Chronic urticaria exacerbated with sun exposure with no active rash at that time was diagnosed. It was stated that she still had blisters and hot, itchy skin when in contact with hot water or sunshine in September 2008. There were no lesions that day. In December 2008, it was again noted that she still developed urticaria after exposure to hot water. Although a history of urticaria was reported during this period of time, recurrent episodes of urticaria occurring at least four times during the past 12-month were not shown. In this regard, the Veteran's competent and credible lay statements are nonspecific regarding the frequency of her urticaria. The Board notes, however, that this criteria is met by 2013. Barring any evidence to the contrary, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the frequency portion of this criteria is met. In addition, the evidence clearly shows use of antihistamines. Thus, a 10 percent evaluation is for assignment. A 30 percent evaluation, however, is not met at any point during the appeal period. At no point prior to May 1, 2013 does the Veteran allege, or the record indicate, recurrent debilitating episodes that require intermittent systemic immunosuppressive therapy Furthermore, recurrent debilitating episodes occurring at least four times during the past 12-month period, requiring intermittent systemic immunosuppressive therapy for control is not shown by the record since May 1, 2013. In this regard, during the May 2013 VA examination the Veteran's disability was reported as intermittent and progressive. She was not on any current medication. Local symptoms were itching and burning sensation with no systemic symptoms. Her episodes during the last two months were once in two months but not debilitating. In the past, she treated with topical ointments with some relief. There were no lesions or scarring anywhere on the exposed/unexposed parts of the body. These findings are also against a higher rating. The Board has considered the application of other potentially applicable diagnostic codes. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). But the evidence of record does not indicate any exfoliative dermatitis or erythroderma, american leishmaniasis, old world leishmaniasis, discoid lupus, erythematosus or subacute cutaneous lupus erythematosus, tuberculosis luposa/lupus vulgaris, bullous disorders, benign or malignant skin neoplasms, other infections of the skin, cutaneous manifestations of collagen vascular disease not listed elsewhere, papulosquamous disorders not listed elsewhere, vitiligo, diseases of keratinization, urticaria, primary cutaneous vasculitis, erythema multiforme, acne, chloracne, scarring alopecia, alopecia areata, hyperhidrosis, or malignant melanoma, eczema, or dermatophytosis. 38 C.F.R. § 4.118, Diagnostic Codes 7807-7811, 7813, 7815-7833 (2013). The criteria used to evaluate disabilities involving the skin were revised effective October 23, 2008. See Schedule for Rating Disabilities; Evaluation of Scars, 73 Fed. Reg. 54,710 (Sept. 23, 2008). These revisions apply to the criteria used to rate scars. As indicated throughout the relevant medical records, there are no scars related to the Veteran's skin condition. Accordingly, although the old and new criteria are technically considered herein, the applicable diagnostic criteria are identical. Compare 38 C.F.R. § 4.118 , Diagnostic Codes 7806-7833 (2007) with 38 C.F.R. § 4.118, Diagnostic Codes 7806-7833 (2013). Migraines The Veteran appeals the denial of a rating higher than 10 percent for mixed tension and migraine headaches prior to May 1, 2013 and 30 percent thereafter. The Veteran's disability has been evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under Diagnostic Code 8100, a 10 percent rating is assigned where there is evidence of characteristic prostrating attacks due to migraines that average one every two months lasting over several months. A 30 percent rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A maximum 50 percent rating is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. In light of the evidence summarized below, the Board finds that a rating of 30 percent is warranted for mixed tension and migraine headaches prior to May 1, 2013. In this regard, the Veteran's headaches were described as moderate in severity in January 2008. During the May 2008 VA examination, the Veteran reported having about four headaches monthly that lasted from one hour to several days. The headaches were bilateral, and with nausea and vomiting occurring about once to twice in a month. She was photosensitive and phonosensitive. With severe headaches, normal ordinary activities were not possible. She was not working at that time. Chronic mixed tension migraine headaches were diagnosed. In June 2008, the Veteran reported very severe headaches. She stated that she had headaches in the front three times a week which were throbbing in nature. The pain level was 6-7 out of 10. She described headaches occurring about twice weekly with pain lasting three to five hours in July 2008. The pain was in the frontal/temporal area. Bright lights, abrupt movement, or loud sounds caused the pain to intensify. The Veteran reported migraines once per week in May 2009. A complaint of headaches off and on for the past week was reported in March 2010. They were described as frontal in nature with pressure on the eyes; some were associated with nausea and photophobia. The evidence summarized above supports a 30 percent rating. At no point, however, does the evidence indicate entitlement to a 50 percent evaluation. Although she has provided competent and credible testimony that some of her headaches are associated with nausea and photophobia, and an inability to perform normal ordinary activities when they are severe, the evidence does not suggest that Veteran's headaches are manifested by prolonged attacks productive of severe economic inadaptability. During the May 2008 VA examination, the Veteran reported four headaches monthly that lasted from one hour to several days. The headaches were bilateral, and with nausea and vomiting occurring about once to twice in a month. She was photosensitive and phonosensitive. With severe headaches, normal ordinary activities were not possible. She was not working at that time. A May 2013 VA examination noted headaches occurring once in two weeks lasting up to four hours were reported. They were noted to be prostrating about 90 percent of the time. Nausea was present and vomiting frequency had increased with headaches each time for the last six months. It was noted that the Veteran was unemployed at that time. While the record reflects persistent headaches with nausea, vomiting, photosensitivity and phonosensitivity when severe, the preponderance of the evidence shows the headaches are not prolonged attacks as they usually resolve within hours, although the Veteran did report falling asleep with a headache and waking up with a headache. Additionally, however, severe economic inadaptability has not been shown. Although the Veteran is unemployed, there is no showing that her unemployment is caused by her migraines - the Veteran herself has not made this allegation. In sum, neither the lay or medical evidence demonstrates that the criteria for a 50 evaluation have been met for any period during this appeal. The Board has considered the application of other potentially applicable diagnostic codes, but the Veteran's headaches are properly rated under this diagnostic code for headaches and the other neurological diagnostic codes are not applicable. See Schafrath, 1 Vet. App. 589; 38 C.F.R. § 4.124a (2013). Lumbar Spine The Veteran appeals the denial of rating higher than 20 percent disabling for lumbosacral strain. The Veteran's disability is rated under Diagnostic Code 5237, which contemplates forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2013). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 (2013) are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Under the general rating formula for diseases and injuries of the spine, a 40 percent rating is assigned for forward flexion of the thoracolumbar spine is 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; and 100 percent for unfavorable ankylosis of the entire spine. Note (1) specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (2): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (5): Based on the evidence presented, the Board finds no basis for assigning a rating higher than 20 percent for the Veteran's lumbar spine disability. To warrant a higher rating, the evidence must show forward flexion of the thoracolumbar spine is 30 degrees or less or that there is favorable ankylosis of the entire thoracolumbar spine. Throughout the time period, the Veteran reported chronic back pain that was consistently in excess of 6/10. In January 2008 VA records, there was negative straight leg raise testing. A March 2008 VA record noted questionable nerve root involvement with disc herniation. In March 2008 the Veteran reported ongoing low back pain that radiates down the thighs. She denied any loss of control of bowel or bladder. During the May 2008 VA examination, she reported low back pain that was sharp in nature. She was independent in activities of daily living but had limited ambulation and standing tolerance. She was unemployed and unable to participate in recreational activities. The spine was symmetrical, posture normal and gait antalgic due to the right anterior tibial border pain. She had forward flexion to 50 degrees and extension to 10 degrees. Pain began at 15 degrees. There was continued pain with repetitive use times three in the lumbosacral area without change in range of motion. Lumbosacral stain moderately severe was diagnosed. The Veteran did not use assistive devices and had no unsteadiness or falls. There were flare-ups after walking or standing for 30 minutes. 2009 and 2010 VA records indicated continuing complaints of low back pain. An April 2009 VA record noted normal reflexes. The Veteran reported frequent spells with her back. In May 2009, there were negative straight leg raises. The May 2013 VA examination revealed similar findings to the March 2008 VA examination. Forward flexion was to 50 degrees and extension to 20 degrees. There were no muscle spasms or guarding but local tenderness present in the lumbosacral region. Her gait was normal. Moderate mechanical lumbar strain was diagnosed. Repetitive use did not cause additional limitation of motion or additional functional limitations. The above findings warrant a 20 percent rating and no higher. At most, the evidence shows lumbar spine flexion limited to 50 degrees, even when considering pain. Although pain was noted at 15 degrees in 2008, pain itself does not rise to the level of functional loss as contemplated by VA regulations; rather, pain must result in functional loss - it must limit the ability to perform the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Because pain did not cause any additional functional loss, and forward flexion of the thoracolumbar spine was in excess of 30 degrees and favorable ankylosis is not shown, a higher rating is not warranted. The Board has considered the requirements of 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). Neither the lay or medical evidence, however, reflects that the requirements for a higher rating are met. To the extent that the Veteran reports lumbar pain during this time, the Board notes that the current rating contemplates periarticular pathology productive of painful motion. 38 C.F.R. § 4.59. With regard to neurologic abnormalities, the Board notes that the Veteran has reported sharp pain starting at the mid back that radiates down to her legs. She also reported urinary urgency at times. A March 2008 VA record noted questionable nerve root involvement with disc herniation. But the May 2008 VA examination revealed sensation was intact bilaterally, reflexes were symmetrical and Lasegue's sign was intact. The May 2013 VA examination also revealed normal sensory, motor, reflexes and rectal findings. Furthermore, an April 2009 outpatient treatment record revealed no radiculopathy type symptoms. There were also no changes in bladder or bowels. The Veteran has provided competent and credible reports of symptoms, such as radiation of pain. But the objective findings regarding strength, sensation, and even reflexes are largely normal. These findings were made upon the results of objective testing done by qualified medical professionals. The Board concludes that the findings of skilled professionals in this instance are more probative than the Veteran's lay statements as she does not exhibit the expertise to make such complex neurological findings. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). A separate compensable evaluation for neurological abnormalities associated with the lumbar spine is not warranted. The Board has also considered whether the Veteran's service-connected lumbar spine disability would warrant a higher rating if rated on the basis of incapacitating episodes. The Veteran, however, has not reported any incapacitating episodes. In light of the lack of evidence demonstrating any episodes requiring bed rest prescribed by a physician and treatment by a physician for IVDS, and indeed, in light of the lack any assertion on the part of the Veteran that the criteria for incapacitating episodes have been met, the Board finds that a higher rating under the Formula for Rating IVDS Based on Incapacitating Episodes is not warranted. Extraschedular evaluations Regarding referral for extraschedular consideration, consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The Board finds that neither the first nor second Thun element is satisfied here. The Veteran's service-connected urticaria is manifested by recurrent hives and skin irritation and is treated with antihistamines and topical lotion. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule because the diagnostic codes in the rating schedule address the frequency of the skin condition and the medications used to treat the condition. See 38 C.F.R. § 4.118. The Veteran's service-connected headaches are manifested by prostrating attacks that occur frequently and are accompanied sometimes by nausea, vomiting, photosensitivy and phonosensitivity. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule because the diagnostic codes in the rating schedule address the frequency of the headaches, the severity of the headaches, and resulting impairment on employment. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. Finally, the Veteran's service-connected lumbar spine condition is manifested limitation of motion, pain, and functional loss such as limitation of walking. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule because the diagnostic codes in the rating schedule contemplate factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. See 38 C.F.R. §§ 4.45, 4.59, 4.71a, Diagnostic Codes 5235-5243; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. In particular, the Veteran does not contend, and the evidence of record does not suggest, that her service-connected disabilities have caused her to miss work or have resulted in any hospitalizations. The Board finds, therefore, that the Veteran's service-connected disabilities do not result in marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). Thus, even if her disability picture was exceptional or unusual, referral would not be warranted. ORDER Entitlement to a 10 percent evaluation, but no higher, for urticaria prior to May 1, 2013 is granted. Entitlement to an evaluation higher than 10 percent for urticaria since May 1, 2013 is denied. Entitlement to a 30 percent rating, but no higher, for mixed tension and migraine headaches prior to May 1, 2013 is granted. Entitlement to an evaluation higher than 30 percent for mixed tension and migraine headaches since May 1, 2013 is denied. Entitlement to an evaluation higher than 20 percent for lumbosacral strain is denied. ____________________________________________ K. MILLIKAN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs