Citation Nr: 18143226 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 16-28 770 DATE: October 18, 2018 ORDER Entitlement to service connection for post-traumatic stress disorder (PTSD) is denied. Entitlement to service connection for other acquired psychiatric disorders, to include an adjustment disorder with depressed mood, is granted. Entitlement to a compensable evaluation for migraine headaches is denied. FINDINGS OF FACT 1. The Veteran served in Afghanistan, in a combat zone but did not actively participate in combat although was subjected to hostile military actions. 2. The most probative evidence of record establishes that the Veteran does not have PTSD, but that his adjustment disorder with depressed mood is of service origin. 3. The Veteran does not have prostrating migraine headaches. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1154(b), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 2. The criteria for service connection for other acquired psychiatric disorder, to include an adjustment disorder with depressed mood, have been met. 38 U.S.C. §§ 1110, 1154(b), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 3. The criteria for a compensable evaluation for migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.20, 4.124a, DC 8100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the Marines from September 2008 to September 2013. His primary military specialty was an aircraft mechanic. He had 5 months of overseas service. His military decorations were the National Defense Service Medal, the Afghanistan Campaign Medal with one star, the Global War on Terrorism Service Medal, Sea Service Deployment Ribbon, Certificate of Appreciation, Letter of Appreciation, and Sharpshooter Rifle Qualification Badge. He was also awarded the Good Conduct Medal and participated in Operation Enduring Freedom in Afghanistan from March 8, 2011 to January 2, 2012. Historically, in pertinent part, a November 7, 2013 rating decision granted service connection for migraine headaches, which were assigned an initial noncompensable disability rating. A July 2014 rating decision denied service connection for an adjustment disorder and confirmed and continued a noncompensable disability evaluation for migraine headaches. That rating decision (which was after a June 2014 VA psychiatric examination that found the Veteran had an adjustment disorder) also granted service connection eligibility for medical care under 38 U.S.C. § 1702 for the purpose of establishing eligibility to treatment based on any active mental illness during or within two years from the date of separation from active service. In September 2014 the Veteran filed a claim for service connection for PTSD, as well as a claim for a compensable rating for migraine headaches. This appeal arises from a January 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) which confirmed and continued the prior denial of service connection for an adjustment disorder and also denied service connection for PTSD. That rating decision also denied a compensable disability evaluation for migraine headaches. Representation By an April 2013 VA Form 21-22, the Veteran appointed the Veterans of Foreign Wars as his representative. By a March 2014 VA Form 21-22, the Veteran appointed the American Legion as his representative. In March 2015 the Veteran executed VA Form 21-22a, Appointment of Individual Representative, which appointed William K. Mattar, an attorney, as the Veteran’s representative but that form specifically states that the “authorization is limited to the investigation of eligibility for benefits only.” In a January 2016 letter William K. Mattar stated the because of the Notice of Disagreement (NOD) to the January 2015 rating decision was of record, a brief would be filed supporting the Veteran’s appeal. By RO letter of January 7, 2016, the RO notified the Veteran of the receipt of his NOD to the January 2015 rating decision but also informed the Veteran of the limited scope of representation by the attorney, William K. Mattar. By letter the next day, January 8th, the RO informed the Veteran that due to the limited scope of the attorney’s representation the RO was “unable to recognize Mr. Mattar as having Power of Attorney.” It was stated that if the Veteran desired to have Mr. Mattar fully represent the Veteran that a new VA Form 21-22a should be executed or clarify the extent or limitation of Mr. Mattar’s representation. That same day a letter was sent to Mr. Mattar notifying him that he was not recognized as having full power of attorney and requesting that a new VA Form 21-22a, be executed and returned to the RO. Received on January 20, 2016, was a new VA Form 21-22a, fully authorizing Mr. Mattar to represent the Veteran. By letters of January 25, 2016, from the RO to the Veteran and to the attorney, it was acknowledged that Mr. Mattar fully represented the Veteran. However, in May 2016 a new VA Form 21-22a, and an attorney fee agreement, was received appointing J. Michael Woods, an attorney, as the Veteran new representative. Thereafter, also in May 2016, William Matter acknowledged the new representation by J. Michael Woods and stated that no further action would be taken by Mr. Mattar and that he was waiving any rights to collect attorney’s fees. In effect, by this letter, Mr. Mattar withdrew his representation of the Veteran. By RO letters of May 24, 2016, from the RO to J. Michael Woods and the Veteran, Mr. Woods was acknowledged as being the Veteran’s representative. A letter of that same date was sent by the RO to Mr. Mattar acknowledging that he no longer represented the Veteran. By letter dated July 27, 2017, J. Michael Woods filed a “Motion for Withdrawal” and requested to withdraw from representing the Veteran and waiving any right to collect attorney fees. It was stated that a copy of that letter was sent to the Veteran. By letter of October 25, 2017, the Deputy Vice Chairman of the Board of Veterans’ Appeals granted the motion to withdraw from representing the Veteran. A copy of that letter was sent to the Veteran. Thereafter, the Veteran did not file a new VA Form 21-22a, appointing any person or organization to represent him. 1. Entitlement to service connection for PTSD 2. Entitlement to service connection for other acquired psychiatric disorders, to include an adjustment disorder with depressed mood Principles of Service Connection Establishing entitlement to service connection generally requires having probative (meaning competent and credible) evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a correlation ("nexus") between the disease or injury in service and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009). A rebuttable presumption of service connection exists for chronic diseases, specifically listed at 38 C.F.R. § 3.309(a) (and not merely diseases which are “medically chronic”), including psychoses, if the chronicity is either shown as such in service which requires sufficient combination of manifestations for disease identification and sufficient observation to establish chronicity (as opposed to isolated findings or a mere diagnosis including the word ‘chronic’), or manifests to 10 percent or more within one year of service discharge (under § 3.307). To establish service connection for PTSD, there must be a medical diagnosis of PTSD, a link between the PTSD diagnosis and the in-service stressor, and “credible supporting evidence that the claimed in-service stressor occurred.” 38 C.F.R. § 3.304(f). VA regulations allow a veteran’s lay testimony alone to constitute the credible supporting evidence required for stressors related to combat in which the veteran engaged, a veteran’s fear of hostile military or terrorist activity, or a veteran’s experience being a prisoner of war. 38 C.F.R. § 3.304(f)(2)-(4). Specifically, if the evidence establishes that the veteran experienced a specific event that caused the claimed stressor (e.g., that the veteran engaged in combat with the enemy), and the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the VA allows the veteran to establish the occurrence of the claimed stressor through the veteran’s “lay testimony alone” when there is no clear and convincing evidence to the contrary. Id. 38 U.S.C. § 1154(b) provides that in the case of a combat veteran lay or other evidence of service incurrence or aggravation is sufficient proof of the occurrence of an event but this deals with what happened during service and not the questions of either the existence of current disability or a nexus to service. Davidson v. Shinseki, 581 F.3d 1313, 1315 (Fed.Cir. 2009) (finding that 38 U.S.C. § 1154(b) does not require controlling weight be given to testimony as to the cause of a combat veteran’s death); see also 38 C.F.R. § 3.304(d). The Board must determine whether the weight of the evidence supports each claim or is in relative equipoise, with the appellant prevailing in either event. However, if the weight of the evidence is against the appellant’s claim, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). Background Service treatment records (STRs) include a December 13, 2011, Post Deployment Health Assessment the Veteran reported having served in Afghanistan. He had not had emotional problems that made it difficult to work. He had not been injured, assaulted or otherwise hurt during his deployment. He had not engaged in direct combat in which he discharged a weapon, he had not felt he was in great danger of being killed, and had not seen dead bodies or people being killed or wounded. He had not had any experience that was so frightening, horrible or upsetting that in the past month he had had nightmares; was constantly on guard, watchful or easily startled; or felt numb or detached from others, activities or his surroundings. He was not worried about his health because of any exposure. A May 17, 2012, Chronological Record of Medical Care, reflects that the Veteran reported having been deployed to Afghanistan from August 2011 to February 2012 but that during that deployment he had not been injured. He did not have any problems which he thought might be related to a head injury or concussion. With respect to PTSD he reported not having nightmares, intrusive thoughts, feeling constantly on guard, watchful or being easily startled, or feeling numb or detached from others, activities or his surroundings. There was an assessment that based on clinical judgment the Veteran did not have PTSD. In a May 17, 2012, Report of Medical History Questionnaire the Veteran reported that his usual military occupation dealt with airframes. As to nervous trouble he reported not having or having had loss of memory or amnesia, or neurological symptoms; frequent trouble sleeping; having received counseling of any type; depression or excessive worrying; having attempted suicide; and not having been evaluated or treated for a mental condition. A May 20, 2013, Chronological Record of Medical Care, reflects that when seen for headaches the Veteran reported not having problems with sleep, stress or mood, and not having any ongoing stressors. A mental status examination was normal. A July 15, 2013, Report of Medical History in conjunction with service separation shows that the Veteran reported having frequent trouble sleeping but not having or having had loss of memory or amnesia, or neurological symptoms; having received counseling of any type; depression or excessive worrying; having attempted suicide; and not having been evaluated or treated for a mental condition. Service personnel records show that the Veteran received punishment for operating a vehicle under the influence of alcohol in July 2011 and in a negligent and reckless manner in April 2012. The Veteran’s initial claim for VA disability compensation benefits, VA Form 21-526EZ, was received in April 2013 and included a claim for service connection for headaches. He did not claim service connection for a psychiatric disorder. He reported having served in a combat zone. With his initial claim for VA disability compensation benefits he submitted copies of his STRs. A November 7, 2013 rating decision granted service connection for a strain of each elbow, patellofemoral syndrome of each knee, a cervical spine strain, a thoracolumbar spine strain with scoliosis, bilateral tinnitus, gastroesophageal reflux disease (GERD), and migraine headaches, with the latter being assigned an initial noncompensable disability rating. Service connection was denied for multiple disabilities, including insomnia. VA outpatient treatment (VAOPT) records reflect that in December 2013 the Veteran had a positive screening for PTSD. A February 27, 2014, statement from a licensed social worker with the Traverse City Vet Center shows that the Veteran was referred to that facility for evaluation and treatment of possible PTSD symptoms. He had served in the Marines and had been deployed to Afghanistan from August 2011 through February 2012, where he received numerous unit citations. In Afghanistan he was assigned to Camp Bashton. When outside the confines of his camp he was subjected to small arms fire and mortar attacks. While on base his camp would be attacked with rockets and mortars, with shells hitting less than 75 yards away at times. On one occasion 50 tons of ordnance was detonated, without notice, creating the appearance of being under attack. In addition to the attacks, there was the constant threat of IEDs (Improvised Explosive Device). He was assigned to work with the Afghan regular Army. Due to the frequency of suicide bombers this was a cause of constant stress and anxiety. He always felt he had to be on high alert and he was in constant fear of injury or death throughout his entire time in Afghanistan. These experiences had had a profound effect on the Veteran. In spite of efforts to relax, he continued to maintain a state of hypervigilance in civilian life. He was always on the look-out for IEDs or some other hazard "waiting to find me." He suffered from nightmares 2 – 3 times a week about his military experiences, causing him to wake in a cold sweat and unable to sleep again. He had difficulty with normal human emotions of joy, sadness, and anger; finding his reaction to be numbness which led to isolation. He also continued to struggle with anxiety and was preoccupied with thoughts of failure and not being successful. His symptoms were persistent in nature and meet the criteria for PTSD, as defined by the DSM-IV. In the Veteran’s VA Form 21-526EZ, was received in March 2014 the Veteran claimed service connection for PTSD and claimed an increased rating for headaches. On VA Initial PTSD Disability Benefits Questionnaire (DBQ) in June 2014 by a VA psychologist the Veteran’s electronic VA records were reviewed, including inservice clinical records. The examiner concluded that based on an evaluation the Veteran did not have a diagnosis of PTSD that conformed to DMS-5 criteria. His symptoms did not meet the diagnostic criteria for PTSD under DSM-5 criteria and the diagnosis was an adjustment disorder, which was considered less likely than not related to military service. With respect to stressors the Veteran reported that the worse trauma was just everyday life in a combat zone. He had been nervous around the foreign nationals, and felt he had to keep eye on them. He had been told that an estimated 10 to 20 percent of them that were sleepers, i.e., enemy. His worst trauma was when his unit was hit by mortars. The first day he got there he went to chow and was alone in the chow hall with all the nationals that worked there, and was outnumbered 50 to one. He did not witness deaths, but saw Humvees hit by IEDs. Also, he read in the Marine Corps Times about the suicide of a fellow soldier with whom he had gone to boot camp. There were constantly people that died and, although he did not witness any deaths, he had seen the caskets. His unit would stand in formation for the caskets. With respect to symptoms, the Veteran reported having a hard time sleeping because he had a variety of thoughts going through his mind. He was often awakened by trains that rolled by his house and the sound of the trains sometimes entered his dreams and became “really weird." "Fire alarms in town" reminded him of the alarms during deployment. He was once startled when some kids threw some fireworks. He liked to have his back to a wall when at a restaurant. The Veteran reported that he enjoyed anything outdoors, e.g., camping, fishing, and hunting, and he remained very active. He had several friends that he continued to stay in touch with. He reported doing well in his full-time work and hoped to advance. He had good interpersonal relationships on the job. The examiner noted that the Veteran had no specific combat duties reported in post-deployment screening. A December 2011 Post-deployment screening revealed that he denied any direct combat duties involving weapon discharge; denied seeing dead or wounded; and denied feeling in any danger. The examiner found that none of the Veteran’s reported stressors met Criterion A, i.e., they were not adequate to support a diagnosis of PTSD. The examiner summarized the relevant evidence as being the Veteran’s reports of four (4) different stressor events during his deployment. However, based on DSM-5 criteria, these claimed stressors would less likely than not meet criterion A for PTSD. The Veteran initiated some mental health treatment services sometime after discharge, and he had been given some medication, with some overlap of medication use with reported headaches. On transparent, broad symptom screening tool, some very mild mixed symptoms were reported. Also, the Veteran had the pre-service onset of alcohol use problems, including legal problems with additional legal consequences during service in 2011, i.e., driving under the influence. The examiner concluded that based on the examination there was inconclusive evidence to support a diagnosis of PTSD. There was evidence suggesting the probable onset of an adjustment disorder following service, as the Veteran re-integrates into civilian life. The adjustment disorder was considered less likely than not related to military service. In VA Form 21-0781, Statement in Support of Service Connection for PTSD, in September 2014 the Veteran reported that in November 2013, during his deployment from August 2011 to February 2012, controlled detonations were an ongoing occurrence with notification. Approximately 3 months into his deployment, a controlled detonation occurred but, on that occasion, it was without notification. He and others were in the morale tent at the time and he and the others feared for their safety and went for their rifles thinking they were being attacked. His unit had also often experienced incoming mortar fire. On one occasion a mortar landed on a basketball court within 200 feet of their work site. That mortar had not detonated and the "EOD" team cleared the area and removed devise. On VA PTSD Disability Benefits Questionnaire (DBQ) in December 2014 by a VA psychologist the Veteran’s electronic VA records were reviewed, including inservice clinical records. The examiner concluded that based on that evaluation the Veteran did not have a diagnosis of PTSD that conformed to DMS-5 criteria. His symptoms did not meet the diagnostic criteria for PTSD under DSM-5 criteria and the diagnosis was an adjustment disorder with depressed mood. It was reported that while in the Marines the Veteran had spent five years as an Airframe Mechanic. His record was generally good, discipline wise, but he did get a DUI and lost one level rank over it, being discharged at E3 when he had been an E4. He was deployed to Afghanistan for six months in 2011 and 2012. The examiner reported that a stressor of mortar fire, having once landed 150 feet away but not detonating, was related to a fear of hostile military or terrorist activity and was adequate to support a diagnosis of PTSD. A stressor of having been in a mess hall with many foreign nationals employed to work there, when the Veteran felt anxious and fearful, was not adequate to support a diagnosis of PTSD. After a mental status examination, the examiner reported that the Veteran’s depressed mood and disrupted sleep were consistent with an adjustment disorder with depressed mood. The Veteran was afforded several psychological questionnaires for evaluation. It was reported that: It is as likely as not that his adjustment issues are caused by a combination of stressors identified during deployment in the body of the report above, and to his adjustment back to civilian life after leaving the service in 2013, which is here interpreted as a direct effect of serving in the military. The examiner reported that the conclusion and opinion statements were based on the Veteran’s interview, review of treatment and other records in the electronic claims file, administration and interpretation of psychological testing, and examiner training and experience in diagnosing mental health conditions, with specialized experience with service personnel and combat veterans. On VA PTSD Disability Benefits Questionnaire (DBQ) in May 2016, by the VA psychologist that conducted the June 2014 VA psychiatric examination, the Veteran’s electronic VA records were reviewed, including inservice clinical records. In fact, the examiner extensively cited to relevant evidence of record and conducted a mental status examination. It was opined that the Veteran did not have a psychiatric disorder. In response to the query of whether the Veteran had a diagnosis of (a) adjustment disorder which was at least as likely as not (50 percent or greater probability) incurred in or caused by military service, the examiner responded in the negative, stating that “there is no conclusive evidence to support a service connected 'adjustment disorder' at this time.” The rationale was (1) that there was no psychometric evidence to support an active symptom profile; (2) adjustment disorders by definition were generally diagnosed in relationship to a specified stressor that generally resolves within 6 - 12 months; (3) there was no evidence of any treatment engagement for mental health concerns since late 2014; and (4) the Veteran reported a solid work history, good social network and active leisure pursuits. Analysis It is conceded that the Veteran was in a combat zone and, as such, was at least at times in fear for his life due to hostile enemy activity and thus would have experienced stressors sufficient to cause PTSD. However, this does not necessarily mean that he actually developed PTSD as a result of any such stressor(s). The Board is aware of the statements of the Veteran that following his tour in Vietnam he had psychiatric symptoms. On the other hand, the majority of the clinical records clearly documents that the Veteran only had an adjustment disorder. In this regard, the fact that PTSD screening was positive at the time of VAOPT and a counselor at a Vet Center has reported that the Veteran has PTSD is inconclusive because there were no psychological tests and not in depth psychiatric examinations. The examinations conducted specifically to determine whether the Veteran had PTSD were by the VA examiners in June and December 2014 and May 2016. Unfortunately, those examiners found that the Veteran did not have PTSD. These medical opinions are given far greater probative weight than the mere conclusory statement of a Vet Center counselor and VAOPT notes because they conducted specifically to determine if the Veteran had PTSD and, moreover, at that one of the examination s the Veteran was afforded a battery of written psychological tests. Moreover, the VA examiners specifically addressed whether the Veteran had the symptomatology which are diagnostic of PTSD, and the VA examiners inquired as to the Veteran’s past personal, occupation, and medical history and conducted mental status examinations. In sum, all the VA examiners concluded that the Veteran did not have PTSD. These opinions were rendered by two VA psychologists, with the December 2014 opinion having also been based not only on the Veteran’s history, his complaints, and mental status examination findings but also on psychological evaluations. These opinions far outweigh the opinion of the licensed social worker of a Vet Center because the VA psychologists have greater training, education, and experience in the diagnosing of mental disorders. Accordingly, the Board must find that the results of the three negative VA psychiatric examinations far outweigh the sole favorable opinion of a licensed social worker and that the preponderance of the evidence shows that the Veteran does not have PTSD. As to a psychiatric disorder other than PTSD, the licensed social worker did not render any opinion as to the existence of any psychiatric disorder other than PTSD. Of the three VA psychiatric opinions rendered addressing a psychiatric disorder other than PTSD, the June 2014 opinion was that that Veteran had an adjustment disorder which was of postservice origin. The December 2014 opinion was that he had an adjustment disorder which was partly due to his military service and partly due to his attempts at postservice adjustment to civilian life. The May 2016 opinion was that the Veteran did not have an adjustment disorder, or in fact any acquired psychiatric disorder, noting that adjustment disorders generally resolved within a half a year to a year. In this regard the Board notes that the May 2016 VA examiner, who found no psychiatric disability including no adjustment disorder, had conducted the June 2014 examination at which time an adjustment disorder was found. By inference, that examiner appears to suggest that the Veteran had an adjustment disorder at the time of the June 2014 examination which had resolved by the time of the May 2016 examination. However, this was not expressly stated. Even if the VA psychologist that conducted the June 2014 and May 2016 VA examinations is correct, i.e., that the Veteran had an adjustment disorder which had resolved, inasmuch as the Veteran filed a claim for service connection for a psychiatric disorder in March 2014 he had an acquired psychiatric disorder during his appeal. The requirement of a current disability is fulfilled if a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Accordingly, service connection for an adjustment disorder with depressed mood is warranted. 3. Entitlement to a compensable evaluation for migraine headaches Rating Principles Ratings for a service-connected disability are determined by comparing current symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which is based as far as practical on average impairment in earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C. § 1155. Disabilities are viewed, and examinations are interpreted, historically, in order to accurately reflect the elements of disability present. 38 C.F.R. §§ 4.1, 4.2. A higher disability rating is assigned if a disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All the elements specified in a disability grade need not necessarily be found, although coordination of disability ratings with impairment of function is always required. 38 C.F.R. § 4.21; but see Camacho v. Nicholson, 21 Vet. App. 360, 366 - 67 (2007) and Middleton v. Shinseki, No. 2013-7014, (Fed. Cir. Aug. 16, 2013) (if disability rating criteria are written in the conjunctive, all required elements must be shown for assignment of a higher rating and 38 C.F.R. § 4.7 cannot be used to circumvent the need to demonstrate all required criteria). A higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Conversely, if [the applicable DC] does specifically contemplate the effects of medication, then Jones is inapplicable.” McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016) (en banc). Separate ratings may be assigned either initially or during any appeal for an increased rating for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119 (1999) (initial staged ratings). Under DC 8100, migraine headaches with characteristic prostrating attacks averaging one in two months over the last several months are rated as 10 percent disabling, and with less frequent attacks a noncompensable rating is assigned. A 30 percent disability rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. Migraine headaches manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability warrant a 50 percent disability rating. 38 C.F.R. § 4.124a, DC 8100. No higher schedular rating in excess of 50 percent is provided under Diagnostic Code 8100. VA regulations do not define "prostrating;" nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes DC 8100 verbatim but did not specifically address the matter of what is a prostrating attack.). By way of reference, the Board notes that according to MERRIAN WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "prostration" is defined as "complete physical or mental exhaustion." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), in which "prostration" is defined as "extreme exhaustion or powerlessness." To summarized, the term prostrating, as used in DC 8100, means to lie down because of exhaustion, or more precisely in terms of headaches due to being powerless, overcome or lacking vitality. The term “characteristic” while not defined in DC 8100, means less than “completely” prostrating headaches. Also, “characteristic prostrating attacks” contemplated for a 30 percent rating does not contemplate a complete inability to function, as does the “completely prostrating and prolonged attacks” productive of severe economic inadaptability for a 50 percent rating. The Board notes that Stedman’s Illustrated Medical Dictionary, 26th Edition, at page 317, defines “characteristic” as meaning “[t]ypical or distinctive of a particular disorder.” Webster’s New College Dictionary, 3rd Edition, at page 192, defines “characteristic” as “[a] distinguishing attribute or element.” Dorland’s Illustrated Medical Dictionary, 31st Edition, at page 343, defines “characteristic” as “typical of an individual or other entity.” In sum, in the context of DC 8100 the term characteristic means that which is typical of a particular disorder. VA regulations also do not define "economic inadaptability." However, the Court has noted that nothing in DC 8100 requires the Veteran to be completely unable to work in order to qualify for a 50 percent rating. See Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). The matter of whether any particular symptoms or behavior associated with headaches are “characteristically” those associated with headaches is not something which is generally discernible by laypersons. In other words, some symptoms or behaviors which may be reported to be associated with or accompanying headaches may not, in fact, be characteristic of headaches. For example, such things as nystagmus, auras, nausea, vomiting, photophobia, and difficulty concentrating can be characteristic of a headache (although the term characteristically is used in DC 8100 with respect to whether the headaches are prostrating, as opposed to whether any specific symptom or group of symptoms are characteristic of tension or migraine headaches). This distinguishes whether or not certain symptoms or behavior are characteristic of headache but it necessarily also means that it must also be considered in addressing whether the symptoms or behaviors are “characteristically” prostrating under DC 8100 because any such symptoms or behaviors which are not characteristic of the service-connected headaches may be due to other causes or etiology(ies) for which service connection is not in effect or which is service-connected and assigned a separate disability rating. Thus, any such symptoms or behaviors which are not characteristic of the service-connected headaches and which are due to such other causes or etiology(ies) may not be considered for rating purposes. See 38 C.F.R. § 4.14 (the “use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided.”). Thus, whether the Veteran’s symptom complex manifested by headaches are those which “characteristically” produce prostration is best left to the domain of competent clinical assessments. Also, DC 8100 does not require ‘incapacitating episodes,’ much less define that term for purposes of headaches. See Prokarym v. McDonald, 207 Vet. App. 307, 310-11 (2015) (holding that terms used to describe a disability in one diagnostic code do not necessarily apply to other disabilities). The term “incapacitating episodes” is consistently defined throughout the Rating Schedule as one that requires bedrest and treatment ‘by a physician.’ See, e.g., 38 C.F.R. § 4.71a, DC 5243 Note (1) (“an incapacitating episode is a period of acute signs and symptoms . . . that requires bed rest prescribed by a physician and treatment by a physician”); 38 C.F.R. § 4.97, DCs 6502-6601 Note (“An incapacitating episode is one that requires bedrest and treatment by a physician.”); 38 C.F.R. § 4.114, DC 7345, Note (1) (‘incapacitating episode’ means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician’).” It is undisputed that DC 8100 does not use the term “incapacitation” or “incapacitating.” However, the very description of the degree and nature of the Veteran’s impairment during his headaches, as described by lay evidence, shows that at least as applied in this case the terms prostrating and incapacitating are essentially the same. Of course, this does not mean that under DC 8100 to establish that the headaches were incapacitating, or prostrating, that bedrest or treatment by a physician is required. The Board must determine whether the weight of the evidence supports each claim or is in relative equipoise, with the appellant prevailing in either event. However, if the weight of the evidence is against the appellant’s claim, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). Background On VA Initial PTSD Disability Benefits Questionnaire (DBQ) in June 2014 it was noted that the Veteran took Amitriptyline for migraines. On VA DBQ for headaches in June 2014 the Veteran’s VA electronic records were reviewed. Since moving from Michigan in 2013 the Veteran had had VA treatment for headaches only on one occasion, in March 2014. He now reported his symptoms had worsened but he had not returned for VA treatment to report the increase in symptoms. He was advised to do so, in the event other problems might exist. The Veteran reported that his head pain was frontal, although apparently a CT of his brain had been negative. He stated that he had headaches every day, and it was of gradual onset. The pain was, at its least 3 to 4 on a scale of 10 (3-4/10) and at its worst was 8 - 9/10. The headaches did not fit a usual pattern. There were no prodromal symptoms, no auras, and no vomiting. However, he would have nausea if he rode in a car, but was not driving, as well as photophobia and sensitivity to noise. The headaches were not cyclic or seasonal. They occurred without apparent causation. He could not identify precipitating factors, or aggravating factors. He had been prescribed Sumatriptan, which he took 5 to 6 times a week. By record, it appeared he took one Sumatriptan tablet every 3 days. There were no reports of prostrating attacks. There was no mention of an inability to function in any of the treatment notes. He reported having trouble going to sleep, but further stated that he generally got 8 hours of sleep each night, even though he lived by a train tracks and the trains awoke him on occasions. The Veteran reported that when he had headaches he had sensitivity to light and sound, and he also had nausea without vomiting or weight loss. He reported having constant frontal head pain. The examiner reported that the Veteran did not have characteristic prostrating attacks of migraine or non-migraine headache pain. Also, after a physical examination, which included a neurological evaluation, the examiner reported that the Veteran's headaches did not impact his ability to work. The examiner further commented that in reviewing treatment records the Veteran had 18 clinical notes dating to February 2014, and there was not one entry where the Veteran reported sound or noise sensitivity and there were no entries regarding complaints of nausea. The examiner noted that although the Veteran stated his migraines had worsened, his treatment records did not show an increase in symptoms. There was no mention of associated symptoms of nausea, light or noise sensitivity and the Veteran has not taken the time to follow up with his treating clinician due to a reported increase in migraine or headache symptoms. On VA PTSD Disability Benefits Questionnaire (DBQ) in December 2014 it was reported that the Veteran took Amitriptyline for migraine headaches. He reported that alcohol made his headaches worse, so he had substantially curtailed any alcohol usage and only indulged moderately, on infrequent occasions. On VA DBQ for headaches in December 2014 the Veteran’s VA electronic records were reviewed. The Veteran reported that his headaches had been worse but recently the dose of Amitriptyline was increased and the severity had improved. The frequency of the headaches had not changed. He got 3 migraines per week, but they were not prostrating and he could stay at work when he had a migraine. He had medication to take when he got one. He got some nausea if he was in a car, but not otherwise. His head pain was localized to the back of his head. Typically, the head pain lasted less than one day. He did not have characteristic prostrating attacks of migraine or non-migraine headache pain. The examiner concluded that the Veteran’s migraines did not impact his ability to work. An April 2015 VAOPT record shows that the Veteran had had a reduction in the frequency and severity of his migraines which he attributed to his increased Amitriptyline dose. The assessment was that the migraines had had a good response, and if the Veteran was one year in relative remission, consideration would be given to a slow tapering off his medication. It seemed that his life was pretty stable and that his headaches were fading away. Analysis The Board notes that the Statement of the Case (SOC) stated, at page 26, that: The VA defines a prostrating attack of headaches as unilateral pain with pulsating quality, moderate to severe intensity, with nausea, vomiting, photophobia, phonophobia and possibly preceded by an aura or general feeling of being unwell. The headache may extend to the neck, shoulders, produce scalp tenderness and a period of sleep. A prostrating headache attack may be supported by evidence showing you were unable to work as a result of the headache, or you were prescribed bed rest by a physician. In this case, regardless of whether the definition of prostrating used in the SOC differs from the other definitions cited above, a compensable disability rating for the Veteran’s headaches is not warranted because they do not cause “prostrating” headaches under any definition. Specifically, the Veteran has not had to take time off from work and has reported that he can, and does, continue to work even when he has a headache. The Board has considered the Veteran’s self-description of his headaches and the impairment he has from the headaches. Significantly, however, the June 2014 VA examiner noted that the Veteran’s clinical treatment records did not corroborate his statements that his headaches had worsened. That examiner, as well as the December 2014 VA examiner concluded that the headaches did not impair the Veteran’s ability to work. Accordingly, the Board must find that the preponderance of the evidence is against finding that the Veteran has prostrating headaches and, so, a compensable disability evaluation is not warranted. 38 C.F.R. §§ 3.102, 4.3. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs