Citation Nr: 1516616 Decision Date: 04/17/15 Archive Date: 04/24/15 DOCKET NO. 12-27 431 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for headaches, to include a rating in excess of 10 percent 30 percent earlier than August 8, 2013. 2. Entitlement to a disability rating in excess of 10 percent for photophobia. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.A. Flynn, Counsel INTRODUCTION The Veteran served on active duty from November 1981 to February 1982. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision that continued the 30 percent evaluation of the Veteran's headaches and continued the 10 percent evaluation of the Veteran's photophobia. An October 2014 rating decision increased the evaluation of the Veteran's headaches to 50 percent effective August 8, 2013. The issue of entitlement to a greater rating for headaches remains in appellate status because the October 2014 rating increase does not represent the highest possible benefit. AB v. Brown, 6 Vet. App. 35, 38 (1993). In March 2015, the Veteran's representative waived RO review of evidence that had been added to the claims file since the issuance of the most recent statement of the case. FINDINGS OF FACT 1. As of February 17, 2013, but not before, the Veteran's headaches are shown to have been productive of very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. 2. At no time has the Veteran's photophobia been productive symptoms distinct from the criteria used to rate the Veteran's headaches. 3. The Veteran's service-connected disabilities do not preclude him from securing and following a substantially gainful occupation consistent with his education and work experience. CONCLUSIONS OF LAW 1. The criteria for a rating of 50 percent for a headache disability, were met as of February 17, 2013, but no earlier. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2014). 2. The criteria for a rating in excess of 10 percent for photophobia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.79, Diagnostic Code 6009 (2014). 4. The criteria for a TDIU have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2014); 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.16, 4.18 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA), which includes an enhanced duty on the part of VA to notify a veteran of the information and evidence necessary to substantiate claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2014). The VCAA also defines the obligations of VA with respect to its statutory duty to assist veterans in the development of their claims. 38 U.S.C.A. §§ 5103, 5103A (West 2014). The Veteran received all appropriate notice in August 2011. Furthermore, neither the Veteran nor his representative has alleged that prejudice resulted from any notice error either on appeal or otherwise. Shinseki v. Sanders, 129 S.Ct. 1696, 1704, 1705, 1706 (noting that "the party that seeks to have a judgment set aside because of an erroneous ruling carries the burden of showing that prejudice resulted"). In sum, the Board finds that the notice provisions of the VCAA have been fulfilled, and that no further notice is necessary. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's post-service medical treatment records, including VA treatment records, have been obtained to the extent they were both identified and available. The duty to assist also includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). More specifically, a VA examination must be conducted when the evidence of record does not reflect the current state of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2014). To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In the instant case, the Veteran was provided with a number of VA examinations. The examination reports indicate that the examiners reviewed the Veteran's claims file and past medical history, recorded his current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that these examination reports are adequate for the purpose of rendering a decision in the instant appeal. 38 C.F.R. § 4.2 (2014); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Moreover, neither the Veteran nor his representative has objected to the adequacy of any of the examinations conducted during this appeal. See Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"). The Veteran was also offered the opportunity to testify at a hearing before the Board, but he declined. The Board finds that there is no indication that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Thus, the duties to notify and assist have been met, and the Board will proceed to a decision. Increased Ratings Generally 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 (West 2014); 38 C.F.R. Part 4 (2014). Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2014). When 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 (2014). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2014). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are appropriate for an increased rating claim, if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25 (2014); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding-the evaluation of the same disability or the same manifestations of a disability under different diagnostic codes-is to be avoided when rating a veteran's service-connected disabilities. See 38 C.F.R. § 4.14 (2014). Increased Rating for Headaches With Photophobia In August 2011, the Veteran filed a claim seeking a rating in excess of 30 percent for his service connected headaches and a rating in excess of 10 percent for his service connected photophobia. During the course of his appeal, the Veteran's rating for his headaches was increased to 50 percent, effective August 8, 2013. The Board will address these ratings together because both the Veteran's headache pain and light sensitivity are manifestations of the Veteran's underlying headache disability. The Veteran's headache disability has been evaluated, in part, under Diagnostic Code 8100, applicable to migraine headaches. Under this Diagnostic Code, in pertinent part, migraines with characteristic prostrating attacks occurring on an average once a month over the last several months warrant a 30 percent rating. Migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability warrant a 50 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2014). The term "prostrating attack" is not defined in regulation or case law. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999) (quoting Diagnostic Code 8100 verbatim but not specifically addressing the definition of a prostrating attack). However, prostration can be defined as "extreme exhaustion or powerlessness." Dorland's Illustrated Medical Dictionary 1554 (31st ed. 2007). The light sensitivity that the Veteran experiences in association with his headaches has been evaluated by analogy under Diagnostic Code 6009, applicable to an unhealed eye injury. Under this Diagnostic Code, incapacitating episodes having a total duration of at least one week, but less than two weeks, during the past 12 months warrant a 10 percent rating. Incapacitating episodes having a total duration of at least two weeks, but less than four weeks, during the past 12 months warrant a 20 percent rating. Incapacitating episodes having a total duration of at least four weeks, but less than six weeks, during the past 12 months warrant a 40 percent rating. Incapacitating episodes having a total duration of at least six weeks during the past 12 months warrant a 60 percent rating. 38 C.F.R. § 4.79, General Rating Formula for Diagnostic Codes 6000 through 6009 (2014). An "incapacitating episode" is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. 38 C.F.R. § 4.79, General Rating Formula for Diagnostic Codes 6000 through 6009 (2014). Turning to the facts in this case, in February 2011, the Veteran reported that he had to take the last quarter off of school due to headaches. In a separate February 2011 treatment record, it was noted that the Veteran had "extreme photophobia" that was successfully treated with tinted contact lenses and sunglasses. In March 2011, the Veteran was in no acute distress, and his pupils were equal, round, and reactive to light and accommodation. The Veteran filed a claim for an increased rating in July 2011. In July 2011, the Veteran sought treatment for headaches that he reported experiencing whenever he was exposed to bright light. The Veteran stated that he continued to experience these headaches when driving to school, despite wearing four pairs of sunglasses. The Veteran indicated that glare from a computer screen could also cause him to develop headaches. In August 2011, the Veteran complained of a headache that he had reportedly experienced for two weeks. Later in August 2011, the Veteran was prescribed oxycodone for his headaches. The Veteran underwent a VA examination in August 2011. The examiner noted that the Veteran experienced weekly headaches that were not prostrating in nature; ordinary activity was possible. The Veteran took continuous medication to treat his headaches, including gabapentin. The Veteran indicated that he experienced headaches all day, and at times he experienced headaches that forced him to go to a dark room and "become a hermit." On one occasion, such an episode reportedly lasted for three months. In November 2011, the Veteran was admitted to the emergency room after experiencing syncope shortly after taking two oxycodone pills in treatment of headache pain and light sensitivity. The Veteran was able to grunt in the emergency room but was otherwise non-responsive. The Veteran's wife reported that the Veteran "usually [slept] it off and [would] be ok." The Veteran was prescribed additional oxycodone. The Veteran submitted his self-assessment of headache pain in the form of a daily log from December 4, 2012, to April 30, 2013. This log shows complaints of pain ranging from mild to severe, and notes that the Veteran took a variety of medications in treatment of this pain, and he often rested in treatment of this pain. In February 2013, the Veteran complained on several occasions to clinicians of a headache with photophobia. The Veteran indicated that he experienced intermittent headaches brought on by bright lights, such as when he shoveled snow the previous day. The Veteran received a Toradol injection in treatment of his headache pain. In March 2013, the Veteran reported that he had been having increased pain from headaches. The Veteran was cautioned to take no more than four tablets of oxycodone in a 24-hour period, and no more than 1000mg of acetaminophen. In a separate March 2013 record, the Veteran indicated that he had experienced a flare-up of headache pain over the past two to three days. The Veteran was treated for headache pain in April 2013 after taking oxycodone without relief; after taking the oxycodone, the Veteran's spouse reported that the "passed out" on the floor for approximately 40 minutes. In April 2013 and May 2013, the Veteran was given injections of Toradol. The Veteran underwent a VA examination addressing his headaches in May 2013, at which time the Veteran stated that he experienced daily headaches throughout the day. The Veteran's headaches ranged from a severity of 3 out of 10 to 10 out of 10, and were typically accompanied by eye pain. The Veteran reported that he had "blacked out" once weekly over the past year. The Veteran took oxycodone and acetaminophen in treatment of his condition. The Veteran was noted to have experienced characteristic, very frequent prostrating attacks of headache pain more frequently than once per month. The Veteran underwent a VA examination addressing his photophobia in May 2013, at which time it was noted that the Veteran had experienced less than one week of incapacitating episodes as a result of his photophobia. The Veteran indicated that he experienced episodes of excruciating eye pain that left him unable to function from minutes to hours. The Veteran indicated that it was always difficult to function without sunglasses. It was noted that examination of the Veteran was difficult due to his extreme photophobia. In an August 2013 Disability Benefits Questionnaire, a physician indicated that examination of the Veteran's eyes could not be performed because the Veteran was too photophobic for an evaluation. It was noted that the Veteran had experienced less than one week of incapacitating episodes as a result of his photophobia. The Veteran claimed that his photophobia with headache led to him passing out. In November 2013, the Veteran reported that he blacked out as a result of pain frequently. The Veteran used tinted contacts and glasses, and he spent most of his time lying in bed in the dark. The Veteran took oxycodone as needed for pain, and his pain was never below a 6 out of 10. The Veteran was prescribed oxycodone and hydrocodone. In a September 2013 Disability Benefits Questionnaire, a physician indicated that the Veteran suffered from severe photophobia. The Veteran took gabapentin, acetaminophen, and oxycodone, and he wore polarized wraparound glasses. The Veteran experienced constant, pulsating or throbbing head pain on both sides of the head that worsened with physical activity. The Veteran experienced severe light sensitivity and flashes in both eyes with pressure. The Veteran reported experiencing syncope with severe pain, and he estimated that the episodes had occurred more than 24 times in the past year. It was noted that the Veteran did not have characteristic prostrating attacks of migraine headache pain, nor did he have very frequent prostrating and prolonged attacks of migraine headache pain. It was noted that the Veteran had very frequent prostrating attacks of non-migraine headache pain more frequently than once per month. In January 2014, the Veteran received treatment in the emergency room for a headache with unconsciousness. A separate January 2014 record indicated that the clinician was talking over the phone with the Veteran while he was driving. In May 2014, a neurologist noted that the Veteran's use of narcotic medicines for eye pain might actually worsen his headaches. In July 2014, it was noted that the Veteran's eye examination under anaesthesia was unremarkable, and only narcotics provided the Veteran with pain relief. In a September 2014 Disability Benefits Questionnaire, the Veteran complained of constant, pulsating or throbbing pain on both sides of the head. The Veteran was noted to experience sensitivity to light and the occasional loss of consciousness. It was noted that the Veteran had very frequent, prostrating and prolonged attacks of headache pain, occurring more frequently than once per month. The Veteran underwent an examination addressing his headaches in January 2015, at which time the Veteran reported having eye pain that led to headache pain. The Veteran was able to reduce his pain to 5 out of 10. The Veteran reported that he was able to function and sleep with this level of pain. The Veteran used rest, ice packs, and darkness to treat his headaches, which ranged in frequency from two to three times weekly to two to three times daily. The Veteran took hydrocodone to control the pain three to four times daily. The Veteran reported that he once experienced pain so severe that he needed to remain in bed for two weeks; the Veteran further reported that he has spent 75 percent of his time in bed as a result of headaches during the past year. The Veteran reported that he had blacked out from headache pain once weekly for the last 25 years, and he had to wear up to five layers of tinted glass to block light. The Veteran was able to drive and read road signs, and he wore tinted contacts for night driving. The examiner indicated that the Veteran experienced very prostrating and prolonged attacks of headache pain once every month. The Veteran underwent an eye examination in February 2015, during which time the examiner noted that the Veteran had not experienced any incapacitating episodes of photophobia during the past year. It was noted that the Veteran was very difficult to examine, and the Veteran reported a history of passing out due to light exposure. Turning now to an evaluation of the appropriate ratings for the Veteran's headache disability, the Board will first address whether the Veteran is entitled to a greater disability evaluation under Diagnostic Code 8100, applicable to migraine headaches, at any time. From August 8, 2013, the Veteran is already in receipt of the maximum 50 percent schedular evaluation under this Diagnostic Code, and the Board will thus not address whether the Veteran is entitled to a greater schedular evaluation since this time. With regard to whether the Veteran is entitled to an evaluation in excess of 30 percent under Diagnostic Code 8100 on and before August 7, 2013, the Board notes that the maximum 50 percent evaluation requires "very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability." Affording the Veteran with the benefit of the doubt, the Board finds that the Veteran first presented symptoms approximating this level of severity on February 17, 2013, which was the first time when the Veteran began seeking more frequent treatment for his headache disability and receiving periodic Toradol injections in treatment of his headache pain. Furthermore, the May 2013 examiner characterized the severity of the Veteran's headaches as very frequent, completely prostrating, and prolonged. Before this time, the Veteran sought only sporadic treatment for his headache pain, and the Board finds that the Veteran's symptoms before this time approximated, at worst, characteristic prostrating attacks occurring on an average of once a month. Thus, the Board will award the Veteran with a 50 percent evaluation under Diagnostic Code 8100 from February 17, 2013. With regard to whether the Veteran is entitled to a disability rating in excess of 10 percent for photophobia under Diagnostic Code 6009, applicable to an unhealed eye injury, the Board observes that the RO's award of a separate evaluation under this Diagnostic Code has produced impermissible "pyramiding" of the Veteran's headache disability when awarded in conjunction with Diagnostic Code 8100. Diagnostic Code 8100 contemplates attacks of headache symptoms productive of extreme exhaustion or powerlessness. Diagnostic Code 6009 provides ratings based on incapacitating episodes as the result of eye trauma. In this case, the medical evidence indicates consistently that the Veteran's photophobia is productive of the Veteran's prostrating headache pain. The Veteran's current 10 percent evaluation under Diagnostic Code 6009 on the basis of incapacitating episodes of photophobia thus compensates the Veteran for the same symptomatology contemplated by Diagnostic Code 8100 on the basis of attacks productive of extreme exhaustion or powerlessness. A greater separate rating under Diagnostic Code 6009 is thus unwarranted. The Board further finds that a greater rating under Diagnostic Code 6009 in lieu of the Veteran's current rating under Diagnostic Code 8100 is not available. While the Veteran has consistently stated that his headaches cause him to experience pain that requires rest, the definition of "incapacitating episode" requires "prescribed" bed rest and treatment by a physician or other healthcare provider. Thus, though the Veteran subjectively indicates that he has a great need for rest as a result of his headaches (even stating in January 2015 that he spent 75 percent of his time in bed), the Board does not find that healthcare providers have prescribed the Veteran with bed rest as a result of his headache symptoms at any time. In fact, VA examiners have consistently found that incapacitating episodes, sufficient to warrant a higher rating, were not shown during the course of the Veteran's appeal. As such, disability ratings in excess of the Veteran's currently staged ratings are thus unavailable to the Veteran under Diagnostic Code 6009. The Board has also considered whether the Diagnostic Code applicable to traumatic brain injury (TBI) would afford the Veteran with greater ratings than those currently assigned, and the Board finds that it would not. Diagnostic Code 8045, applicable to TBI, contemplates subjective symptoms such as headaches. Even if the Board were to find that the Veteran experiences three or more subjective symptoms as a result of his headache disability, such as headache pain, light sensitivity, and fatigability, such symptoms would only afford the Veteran with a 40 percent evaluation under the Diagnostic Code applicable to TBI, which is not greater than the ratings that the Veteran has been awarded under Diagnostic Codes 8100 and 6009 throughout the course of the appeal. A greater rating under Diagnostic Code 8045 is thus unavailable to the Veteran. In sum, the Board finds that a 50 percent rating of the Veteran's headache disability is warranted from February 17, 2013. Greater disability ratings for the Veteran's headache disability and photophobia are otherwise unwarranted. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Considerations The Board has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57 (1993). There is a three step inquiry to determine whether a claim should be referred for extra-schedular consideration. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. 38 C.F.R. § 3.321 (2014); Thun v. Peake, 22 Vet. App. 111 (2008). The Veteran's representative argued in March 2015 that the severity of the Veteran's headaches supported evaluation beyond the schedular criteria. In support of this argument, the Veteran's representative noted that the Veteran experienced "frequent blackouts," used narcotics daily, spent 75 percent of his time in a dark room, required five layers of tinted glass in order to block light, required tinted contact lenses at night, was unable to complete a VA examination due to his photophobia, and was unable to work on a regular schedule in his usual occupation. The Board disagrees with this argument. The schedular criteria for Diagnostic Code 8100, applicable to migraine headaches, explicitly contemplate a symptom picture that is productive of exhaustion, powerlessness, and "severe economic inadaptability." Moreover, in contemplating whether "severe economic inadaptability" is shown, VA is necessarily required to consider all of the Veteran's headache related symptomatology, meaning that the schedular rating criteria have contemplated all of the Veteran's headache symptomatology. The schedular criteria for Diagnostic Code 6009, applicable by analogy to the Veteran's photophobia, contemplate periods of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. The Veteran's pain, use of medicines to control symptoms, eye symptoms productive of the need to rest, and impairment of occupational functioning are thus contemplated by the criteria of Diagnostic Codes 6009 and 8100. To the extent that the Veteran's "blackouts" are not contemplated by the schedular criteria, the Board first observes that such symptoms appear to be associated closely with the Veteran's frequent consumption of narcotic medications; for example, the Veteran received emergency room treatment in November 2011 for a "blackout" following his consumption of two oxycodone pills. Furthermore, even accepting that the Veteran experiences blackouts, the Board cannot find that these blackouts result in marked interference with employment or frequent periods of hospitalization. As will be discussed in further detail below, neither of the Veteran's previous employers cited his blackouts as relevant to the reasons for his termination, nor have clinicians cited the Veteran's blackouts as limiting the Veteran's industrial functioning. While the Board observes two instances during the period on appeal in which the Veteran received treatment for an arguable "blackout," the Board finds that two instances in over four years does not constitute a "frequent period of hospitalization." In sum, it is clear that the Veteran's headache disability impairs the Veteran's ability to work. The schedular rating that is assigned in this case is assigned to compensate in large part for impairment with employment. Referral for consideration for an extra-schedular rating is not warranted. TDIU The Veteran contends that he is unemployable due to his service-connected headache disability. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that a Veteran is precluded, by reason of service-connected disability, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Benefits based on individual unemployability are granted only when it is established that the service-connected disability or disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there are two or more service-connected disabilities, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the purpose of determining whether a Veteran meets the criteria for assigning a schedular TDIU, disabilities resulting from a common etiology and disabilities affecting a single body system are considered to be one disability. Id. In addition, when a Veteran has one disability rated at 50 percent with an additional disability rated at 0 percent or 10 percent, the above-described schedular requirements are considered to have been met. VBA Fast Letter 13-13 (June 17, 2013). Substantially gainful employment is employment that is ordinarily followed by the nondisabled to earn a livelihood, with earnings common to the particular occupation in the community where the employee resides. The term suggests a living wage. Ferraro v. Derwinski, 1 Vet. App. 326 (1991). The ability to work sporadically or to obtain marginal employment is not substantially gainful employment. 38 C.F.R. § 4.16(a) (2014); Moore v. Derwinski, 1 Vet. App. 356 (1991). A Veteran may be considered unemployable upon termination of employment that occurred because of disability, or in which special consideration was given on account of the disability, when it is satisfactorily shown that the Veteran is unable to secure further employment. 38 C.F.R. § 4.18 (2014). The determination as to whether a TDIU is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. Ferraro v. Derwinski, 1 Vet. App. 326 (1991). Any consideration as to whether the Veteran is unemployable is a subjective one that is based upon the Veteran's actual level of industrial impairment, not merely the level of industrial impairment experienced by the average person. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Advancing age and nonservice-connected disability may not be considered in the determination of whether a Veteran is entitled to a TDIU. 38 C.F.R. §§ 3.341(a), 4.19 (2014). The sole fact that a Veteran is unemployed or has difficulty obtaining employment is not enough. A high rating for service-connected disability, in itself, is recognition that the impairment makes it difficult to obtain and keep employment. Instead, the question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Turning to the facts in the instant case, the Veteran is in receipt of a combined 40 percent disability evaluation on and before February 16, 2013 (that is, a combined 30 percent rating for headaches and a 10 percent rating for photophobia) and a combined 60 percent disability evaluation from February 17, 2013 (that is, a combined 50 percent rating for headaches and a 10 percent rating for photophobia). Noting that the Veteran's headaches and photophobia share a common etiology, and affording due consideration to the policy outlined in VBA Fast Letter 13-13, the Board finds that the Veteran's disabilities meet the schedular criteria for a TDIU as of February 17, 2013, although not earlier. 38 C.F.R. § 4.16(a) (2014). Regardless, the ultimate issue is whether the Veteran's service connected disabilities render him unable to secure or follow a substantially gainful occupation. By history, the Veteran has reported that he completed two years of college and previously held jobs as a self-employed carpenter, lawn maintenance worker, and handyman. In August 2011, it was noted that the Veteran's headaches would cause increased absenteeism. The Veteran stated that he could not do many things inside due to his need to wear sunglasses. The Veteran was a full-time student in school for computer training, and he otherwise worked as a handyman. The Veteran was self-employed, so he could manage his time off as needed. The Veteran had been self-employed as a handyman for the past 10 to 20 years, and he had not lost any time from work as a result of his headaches. The Veteran estimated that if he had to work a 40-hour work week, he would miss 75 percent of work. In December 2011, the Veteran submitted an attendance report showing significant absenteeism for classes held between March 2011 and November 2011. In May 2013, a VA examiner indicated that the Veteran's headache disability would impact his ability to work because he could not tolerate exposure to normal ambient lighting. During the Veteran's occasional opportunities for work, the Veteran developed severe headaches with exposure to light, preventing him from functioning. In May 2013, a VA eye examiner indicated that the Veteran's photophobia impacted his ability to work, simply stating that it was "very difficult to function." In August 2013, a physician noted that the Veteran's photophobia would impact his ability to work, and that he would have to have lighting adjusted as a result. In September 2013, a physician indicated that the Veteran's headache disability affected his ability to work because he was unable to look at a computer screen or perform physical activity because such activities exacerbated his constant head pain. In November 2013, the Veteran stated that he was unable to work as a handyman or carpenter because of pain. In a September 2014 Disability Benefits Questionnaire, the Veteran stated that his headache condition impacted his ability to work because people did not want to hire him. The Veteran indicated that he started a job earlier in the year and was accused of sleeping on the job because of "having blackouts" and having to take breaks to cover and ice his eyes. In December 2014, the Veteran stated that he last worked full time in May 2014, and asserted that he became too disabled to work at that time. The Veteran reported that he worked for Manpower from October 2014 to November 2014 and had lost two days from work as a result of illness. The Veteran reported that he had worked for a daycare from April 2014 to May 2014 and had lost 15 days of work as a result of illness. The Veteran reported that he left his last job as the result of his disability, and he had not attempted to obtain additional employment since May 2014. In January 2015, a VA examiner noted that the Veteran stated that he had not worked since September 2014 as a result of his blackout spells due to severe headaches. In February 2015, a VA examiner found that the Veteran's eye disability would impact his ability to work. As a result of the Veteran's extreme photophobia, the Veteran would be unable to function effectively due to lighting, and he would be unable to function in normal lighting without sunglasses. In February 2015, Manpower indicated that it had hired the Veteran from October 2014 to December 2014 as a general laborer. The Veteran worked 8-hour days, and the Veteran's employment was terminated as the result of a lack of workload. The employer did not indicate that the Veteran had lost time from work as the result of disability. In April 2015, a daycare that had employed the Veteran as a janitor from March 2014 to May 2014 indicated that the Veteran was terminated because he was upset over a policy change and threatened to quit and abduct children to his house. The owner of the daycare released the Veteran the following morning. The daycare indicated that the Veteran had not lost time from work as the result of disability. The Board finds that the weight of the medical evidence of record indicates that the Veteran is not unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Instead, while the medical evidence suggests that the Veteran would need to wear sunglasses inside and would possibly need to have lighting adjusted, the Board finds that the evidence does not support a finding that the Veteran is entirely precluded from securing or following a substantially gainful occupation as a result of his disabilities. In making this determination, the Board notes that the conclusions that clinicians have drawn regarding the Veteran's employability are based entirely on the Veteran's subjective report of symptoms that the Board does not find to be entirely credible. For example, while the Veteran reports experiencing frequent blackouts that would impact his ability to work, the Board must observe that the Veteran has consistently reported driving himself throughout the period on appeal (for example, in July 2011, January 2014, and January 2015). The Board finds it to be unlikely that the Veteran would subject himself, his spouse, and others to the dangers of him operating an automobile if he was indeed incapacitated by pain and blackouts as he has described. Similarly, the Board finds that the Veteran's successful daytime operation of an automobile is inconsistent with the Veteran's assertion that he is unable to view a computer screen without debilitating pain. Additionally, the Board finds the Veteran's contentions regarding the impact of his symptoms on his ability to work to lack credibility because the Veteran's past employers made no mention of these symptoms. While the Veteran stated that he lost two days of work from Manpower and fifteen days from a daycare as a result of his headache disability, neither employer indicated that the Veteran had lost any time from work at all. Similarly, while the Veteran has stated that he was terminated from these positions as a result of his disabilities, the employers themselves reported that the Veteran was terminated from one position because of a lack of work, and was terminated from another position because he threatened to abduct children. Thus, the Board observes in both instances that the Veteran's account of his days lost from work and the reasons for his termination deviated significantly from his previous employers' accounts. The Board does not doubt that the Veteran's service-connected disabilities have an effect on his employability, as evidenced by his combined disability rating that is staged at 40 percent and 60 percent. The weight of the evidence, however, does not support a finding that his service-connected disabilities preclude his participation in substantially gainful employment. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. 38 C.F.R. §§ 3.321(a), 4.1 (2014). Indeed, 38 C.F.R. § 4.1 specifically states: "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Thus, upon a thorough review of the evidence of record, the Board finds that the Veteran is not precluded from engaging in substantially gainful employment as a result of his service-connected disabilities. As such, the benefit of the doubt doctrine is inapplicable, and the claim for TDIU is denied. 38 C.F.R. § 5107(b) (2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A disability rating in excess of 30 percent for headaches is denied on and before February 17, 2013. A disability rating of 50 percent, but no greater, is granted for headaches on and after February 17, 2013, subject to the laws and regulations governing the award of monetary payments. A disability rating in excess of 10 percent for photophobia is denied. A TDIU is denied. ____________________________________________ MATTHEW W. BLACKWELDER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs