Citation Nr: 21068772 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 16-08 331 DATE: November 12, 2021 ORDER 1. Entitlement to service connection for a right hip disability is denied. 2. Entitlement to a disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD) prior to March 11, 2015, is denied. 3. Entitlement to an increased 30 percent disability rating, but no higher, for GERD is granted effective March 11, 2015, subject to the laws and regulations governing the award of monetary benefits. 4. Entitlement to a disability rating in excess of 10 percent for right knee degenerative joint disease (DJD) is denied. 5. Entitlement to a disability rating in excess of 10 percent for left knee degenerative joint disease (DJD) is denied. 6. Entitlement to a compensable disability rating for tension headaches is denied. FINDINGS OF FACT 1. The Veteran's right hip disability was not incurred in service and is not otherwise related to service. 2. Prior to March 11, 2015, the Veteran's GERD was not manifested by persistently recurrent epigastric distress, hematemesis, substernal or arm or shoulder pain, or other symptoms productive of considerable impairment of health. 3. Affording the Veteran the benefit of the doubt, since March 11, 2015, her GERD manifested in persistently recurrent epigastric distress, pyrosis (heartburn and/or reflux), regurgitation and substernal pain, which were productive of considerable impairment of health, but not by material weight loss, melena, moderate anemia, or other symptom combinations productive of severe impairment of health. 4. Right knee DJD has not resulted in flexion limited to 30 degrees or extension limited to 15 degrees; and, the preponderance of the evidence is against clinical findings of locking, effusion, ankylosis, subluxation, instability, removal of semilunar cartilage, or impairment of the tibia and fibula at any point during the appeal period. 5. Left knee DJD has not resulted in flexion limited to 30 degrees or extension limited to 15 degrees; and, the preponderance of the evidence is against clinical findings of locking, effusion, ankylosis, subluxation, instability, removal of semilunar cartilage, or impairment of the tibia and fibula at any point during the appeal period. 6. The Veteran's tension headaches did not manifest with characteristic prostrating attacks averaging one in two months over several months at any point of the appeal period. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right hip disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. For the period prior to March 11, 2015, the criteria for an increased evaluation for the Veteran's service-connected GERD in excess of 10 percent have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.114a, Diagnostic Code (DC) 7399-7346. 3. For the period beginning March 11, 2015, the criteria for an increased 30 percent evaluation for the Veteran's service-connected GERD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.114a, Diagnostic Code (DC) 7399-7346. 4. The criteria for a disability rating in excess of 10 percent for right knee DJD or for a separate rating under another Diagnostic Code have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5256, 5257, 5258, 5259, 5260, 5261, 5262, 5263. 5. The criteria for a disability rating in excess of 10 percent for left knee DJD or for a separate rating under another Diagnostic Code have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5256, 5257, 5258, 5259, 5260, 5261, 5262, 5263. 6. The criteria for a compensable evaluation for tension headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.124a, Diagnostic Code (DC) 8199-8100 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2009 to June 2009 and from January 2011 to January 2012, with additional reserve service. In July 2019, the Veteran provided testimony at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) in Boise, Idaho. A copy of the hearing transcript is associated with the claims file. In January 2020, in pertinent part, the Board issued a decision that denied the Veteran's claims of (1) entitlement to disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD); (2) entitlement to a disability rating in excess of 10 percent for right knee degenerative joint disease; (3) entitlement to a disability rating in excess of 10percent for left knee degenerative joint disease; (4) entitlement to a compensable disability rating for tension headaches; (5) entitlement to service connection for a right hip disability; and (6) the request to reopen a claim for entitlement to service connection for a left hip disability. The Board also reopened the Veteran's claim of entitlement to service connection for a right hip disability. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In October 2020 the Veteran and the Secretary of VA (parties) filed a Joint Motion for Partial Remand (JMPR) with respect to the part of the January 2020 Board decision that denied the listed claims above, to vacate and remand the claims back to the Board, which was granted by the Court. In March 2021, the Board remanded the claims for further development, including to obtain such outstanding medical records pursuant to the October 2020 JMPR. There was substantial compliance with the Board's remand directives to decide the claims on appeal at the present time. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Forcier v. Nicholson, 19 Vet. App. 414, 425 (2006). While the claims were in remand status, the RO granted service connection for iliotibial band syndrome of the left hip, which is a full grant of benefits. Thus, this issue is no longer part of the current appeal. The RO properly informed the Veteran of such fact in the July 2021 rating decision. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for a right hip disability. The Veteran asserts that service connection for a right hip disability is warranted because it was incurred in or otherwise a result of service. During the July 2019 Board hearing, the Veteran testified that she was thrown from a bike when she was overseas. She stated that she believed she injured her hip but could not get treatment because of the terrain where she was and when she got off active duty and returned to the United States, she was involved in a vehicle accident. She explained that the vehicle hit her on the driver's side and her hip started popping and she had pain ever since. Her representative indicated that she was talking about the left hip regarding the vehicle accident and the Veteran explained that as to her right hip, she believed it was due to the impact of being thrown off from the bike. The parties to the October 2020 JMPR had found that the Board failed to adequately address a July 2014 outpatient report reflecting complaints of bilateral hip pain. The terms of a Joint Motion will serve as a factor for consideration as to whether or to what extent other issues raised by the record need to be addressed by the Board. See Carter v. Shinseki, 26 Vet. App. 534, 542-43 (2014). Therefore, the crux of the JMPR involved a finding by the parties that the Board had provided inadequate reasons and bases, as discussed above. The Board will address this in its analysis below. After a careful review of the evidence of record, the Board finds that the preponderance of the evidence is against a finding that service connection for a right hip disability is warranted. The reasons follow. As to evidence of a current disability, a July 2015 VA examination report reflects a diagnosis of trochanteric pain syndrome of the bilateral hip. Most recently, following examination in June 2021, a VA examiner found that although the record noted past complaints of right hip pain, there is no objective evidence of a right hip disability at the time of examination and no right hip diagnosis was rendered. As there is evidence of a right hip disability during the pendency of the appeal, the first element of a service-connection claim is met. However, the Board has reviewed the record, including service treatment records and post-service medical records and finds that the preponderance of the evidence is against a finding that a right hip disability had its onset in service or is otherwise related to service. As to an in-service event or injury, the service treatment records confirm the Veteran's report of falling off her bike in May 2011. However, these records do not reflect a complaint of pain in either hip but instead only the Veteran's complaint of right knee pain. The Veteran reported at the time that her pit sergeant "made me come here to get seen [for medical care]." A minor abrasion to the right knee and pinpoint tenderness at the lateral aspect of the right knee was noted. Subsequently, in a July 2011 service treatment record, the Veteran was seen for physical therapy for patellar tendon algia when hip motion was noted to be within normal limits. In an August 2011 service treatment record, the Veteran presented for follow up of the right knee pain since the May 2011 fall off her bike. Objective findings noted special tests which found continued tightness of the hamstrings and hip flexors that were improved from initial evaluation. An assessment was made of chronic knee pain and no mention of the right hip, which would indicate that the tightness of the hip flexor was not significant. Moreover, while tightness of the hip flexors was noted, in a December 2011 Post-Deployment Health Assessment, the Veteran noted only concerns about her health under section 11, as "right knee, headaches." Identified concerns were "physical symptoms" as a "minor concern" and the Veteran was referred to primary care or family practice within 30 days. Under section 13 comments, the examiner documented that the Veteran injured her right knee riding a bicycle, headaches due to the environment, and a rash in the bilateral elbow. Thus, at the time, close to her separation from service, there was no concern of the right hip. Accordingly, the preponderance of the evidence is against a finding of complaints or symptoms related to the right hip during service, and the in-service disease or injury element is not met. The Board also finds the preponderance of the evidence is against a nexus between the right hip disability and service. Upon VA examination in April 2013, the examiner found that there was no diagnosed condition of the right hip. In the July 2015 VA examination report, an October 2014 diagnosis of trochanteric pain syndrome of the right hip was noted. The Veteran complained of bilateral hip girdle pain involving the hip flexors and their attachment at the greater trochanter. The Veteran attributed her right sided lateral hip girdle pain to a reported event during a period of weekend drill/annual training in 2013. Specifically, she reported she was standing in formation during a military event in California and her knees became painful and she collapsed to the ground and claimed she fell on her right hip. The examiner noted a July 2013 record that reflected "low back pain with right hip pain. She noted frequent visits to the VAMC between July 2013 and April 2014 without specific reference to right hip pain. She stated that the medical record was silent with regard to right hip symptoms until an October 2014 rehab medicine evaluation. The examiner concluded that the objective evidence of record does not support a conclusion that a chronic right hip condition was proximately caused by an event occurring during service nor the event reported in 2013. The examiner added that the record was silent for a right hip condition for more than a year after the July 2013 incident, and there is not sufficient evidence to be able to establish a causation link between the July 2013 incident with the current examination findings of the right hip. The examiner explained that the Veteran clearly had more troublesome symptoms involving the soft tissue structures of the hip/pelvic musculature since the prior examination of April 2013, but found no objective evidentiary or medical probability basis to attribute the progression to her Gulf War service or any other aspect of military service at the time. In June 2021, an addendum VA opinion was provided. The examiner concluded that the right hip disability was less likely than not incurred in or caused by an in-service illness, event or injury. The examiner noted that there was no current evidence of ongoing tightness of hamstrings. He documented that there were complaints of hip gridle pain including hip flexors and their attachment at the greater trochanter in 2015 and the reported right sided hip symptoms had resolved. Moreover, the examiner stated that the hip condition was a diagnosable condition with a well-established etiology and not attributable to a Gulf War related illness nor to "exposure to the hazards of the environment during service in Southwest Asia." The examiner wrote that he found no substantial evidence that the soft tissue overuse condition was caused by any aspect of her active service, as opined previously by the April 2013 examiner. He explained that "snapping hip" is a condition that occurred when the iliotibial band slides across the greater trochanter of the hip, which is a soft tissue condition that is not expected to impair hip function in a substantial way. He stated that the objective evidence of record does not support a conclusion that a chronic right hip condition was proximately caused by an event during service nor the event reported in 2013. The Board finds of most probative value the medical opinions of the July 2015 VA and June 2021 VA examiners. The clinical findings withing the VA examination reports and the medical opinions collectively provide competent and probative evidence that weighs against the Veteran's claim because the examiners reviewed the claims file, interviewed the Veteran, performed a physical examination, and provided medical opinions supported by well-reasoned rationale, which was based upon the facts of the case and medical principles, including reference to the Veteran's specific medical records, as cited in the opinions. The Veteran has not offered other probative and competent medical evidence to support her assertions on medical etiology. There are numerous post-service medical records reflecting complaints and treatment for right hip pain; however, these records do not provide a positive nexus regarding the onset, etiology, or relationship of a right hip disability to military service. In regard to the July 2014 VA medical record, the Veteran reported complaints involving the left hip, which she described as feeling pressure when sitting or lying on the left side. She indicated that she had left hip pain while sitting on the bus, during a three-hour ride to the airport. The record shows that the Veteran had right hip pain due to sitting on the right hip to relieve the left hip during this bus ride. The Veteran has clarified during the July 2019 Board hearing that she believed her right hip disability was due to the impact of being thrown off from the bike overseas. She does not contend that her right hip disability is secondary to her service-connected left hip injury, nor does the record suggest such, other than this record of right hip pain during a three hour bus ride caused by the Veteran sitting directly on her right hip for an extended period of time to relieve pressure off the right hip. To the extent that the Veteran alleges that a right hip disability is related to service, she is not competent to attribute the right hip disability to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion is nonprobative evidence. At the present time, there is no competent evidence of a nexus between the current right hip disability and service to weigh against the negative VA opinions. In sum, the Board finds that the Veteran's right hip disability did not manifest in service and that it is not etiologically related to her active duty military service. As the preponderance of the evidence is against the claim for service connection for a right hip disability, the benefit-of-the-doubt doctrine is not for application, and the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Ratings Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects her ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. The percentage ratings in the Rating Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. Diagnostic Codes (DCs) are assigned by the rating officials to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. See 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. See id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3. The Rating Schedule recognizes that a single disability may result from more than one distinct injury or disease; however, rating the same disability or its manifestation(s) under different DCs a practice known as pyramiding is prohibited. See 38 C.F.R. § 4.14. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 2. Entitlement to a disability rating in excess of 10 percent for GERD. The Veteran seeks a disability rating for GERD in excess of the assigned 10 percent rating. The parties to the October 2020 JMPR found that the Board erred when it failed to adequately explain its conclusion that Veteran's GERD is manifested by occasional, as opposed to "persistently recurrent," epigastric distress in light of her July 2019 hearing testimony that she had daily symptoms, regurgitates and cannot hold anything in her stomach. The terms of a Joint Motion will serve as a factor for consideration as to whether or to what extent other issues raised by the record need to be addressed by the Board. See Carter, 26 Vet. App. at 542-43. Therefore, the crux of the JMPR involved a finding by the parties that the Board had provided inadequate reasons and bases, as discussed above. The Board will provide a discussion on the facts cited by the parties below including the Veteran's testimony during the July 2019 Board hearing The Veteran's GERD has been rated by analogy under DCs 7399-7346. DC 7399 is a general reference to the rating criteria for disabilities of the digestive system. DC 7346 provides the rating criteria for hiatal hernia. A 10 percent disability rating is warranted with two or more of the symptoms for a 30 percent disability rating with less severity. A 30 percent disability rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A maximum schedular 60 percent disability rating is warranted for symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Id. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of a disability rating in excess of 10 percent for GERD prior to March 11, 2015, however, affording the Veteran the benefit of the doubt, an increased 30 percent rating is warranted since March 11, 2015. The reasons follow. A May 2014 VA examination report reflects signs and symptoms of the Veteran's GERD of dysphagia, reflux, regurgitation, substernal pain, and two episodes per year each of nausea and vomiting with a duration of episodes less than one day. The Veteran was also noted to have occasional episodes of bowel disturbance with abdominal distress. In March 2015, the Veteran complained of a vomiting issue and not being able to keep anything down. The Veteran was instructed to not brush her tongue but indicated that it continued even though she did not brush her tongue. A June 2015 VA emergency department record includes gastrointestinal symptoms of nausea and vomiting four times that day. The Veteran reported that she had been vomiting every morning and had seen primary health several times for the same symptoms. In July 2015, the Veteran reported that she was still having epigastric discomfort and had pain that radiated into her chest a few days prior with a burning feeling. The pain worsened with eating especially with acidic foods and soda. She explained that food particles would get stuck in her throat and it was hard to swallow, sometimes she would cough it out. The Veteran reported vomiting that had stopped the first week of July. A February 2016 VA medical record documents the Veteran reported that she continued to vomit yellow bile colored emesis, which did not occur every day but was noted on an empty stomach, after eating, and lying down for a couple of hours after eating spicy foods. She indicated there was abdominal pain in her lower quadrant, but no pain noted beneath her right shoulder or back, which increased with spicy foods but not necessarily with fatty or greasy foods. The Veteran stated that she could push on her stomach and cause vomiting to occur and did this when she felt that there was something stuck in her throat or when she felt nauseated. She reported that her stomach ached a lot during the day and requested an evaluation. A March 2016 VA medical record shows the Veteran's complaint of stomach pain with nausea, vomiting and diarrhea for years. She stated that she was otherwise constipated and took a stool softener daily. In a May 2017 VA medical record, it was noted that the Veteran's GERD was controlled and that she was no longer vomiting. In July and August 2017, the Veteran again reported an upset stomach and that she had been vomiting. In September 2017, the Veteran reported being constipated to the point that she was vomiting her food up. An April 2018 VA medical record reflects the Veteran's report of horrible GERD and that her acid had been really bad. The Veteran complained of upset stomach and vomiting in September 2018, November 2018, April 2019, and July 2019. A July 2019 VA medical record shows a follow-up from an emergency room visit for abdominal pain. It was noted that the Veteran had her last bowel movement five days prior and acid reflux caused vomiting. She had epigastric pain in spite of regular omeprazole use. She stated that she had weight gain and felt hungry all the time. As mentioned above, during the July 2019 Board hearing, the Veteran reported that she experienced GERD symptoms everyday which were "pretty bad" and that she would regurgitate and "can't hold anything on [her] stomach." A September 2019 VA gastroenterology consultation shows that the Veteran had abdominal complaints that to the greatest extent seemed to be foregut related. She reported passive regurgitation when she lied down and noted a burning sensation in the midline upper abdomen. She complained of bloating after she ate and occasionally required vomiting after she ate to feel better. An impression of significant reflux disease was provided. This was likely exacerbated by weight gain and constipation and there was a possibility an element of delayed gastric emptying associated with her mood stabilizers. During the June 2021 VA examination, the Veteran's symptoms included pyrosis, regurgitation, reflux, substernal pain, and four or more episodes of nausea and vomiting per year. The Board has reviewed the probative evidence of record including the Veteran's statements and evidentiary submissions and finds that the criteria for a higher 30 percent rating under DC 7346 have not been met or more nearly approximated for GERD prior to March 11, 2015, as the Veteran's gastrointestinal disability was not shown to be productive of considerable impairment of health. The May 2014 VA examination report reflects signs and symptoms of the Veteran's GERD of dysphagia, reflux, regurgitation, substernal pain, and two episodes per year each of nausea and vomiting with a duration of episodes less than 1 day. The Veteran was also noted to have occasional episodes of bowel disturbance with abdominal distress. However, the weight of the evidence demonstrates that her symptoms are of lesser severity than that for a 30 percent rating and do not show that they are productive of considerable impairment of health, as such episodes of nausea and vomiting were only noted to occur twice a year at the time but had increased in severity and frequency after March 2015. The Board finds that since March 11, 2015, the Veteran's symptoms more closely approximated the symptoms for the 30 percent criteria under DC 7346. March 2015 VA medical records start the documentation of the Veteran's complaints of vomiting and not being able to keep anything down. Since this time, the Veteran has continuously sought medical treatment, including multiple visits to the emergency room for GERD symptoms including vomiting/ regurgitation, nausea, abdominal pain, substernal pain, trouble swallowing, food getting stuck in her throat, acid reflux, and constipation as discussed above. While the the term "considerable impairment of health" is not defined in 38 C.F.R. § 4.114, the Board finds that the preponderance of the evidence shows that the Veteran's symptoms have resulted in considerable impairment of health. Therefore, with consideration of the benefit of the doubt doctrine, the Board finds that her symptoms more nearly approximate those required for a 30 percent evaluation from March 11, 2015; however, a rating in excess of 30 percent from that date is not warranted. The preponderance of the evidence demonstrates that a rating in excess of 30 percent is not warranted. Current symptoms of gastroesophageal reflux disease include persistently recurrent epigastric distress, pyrosis, regurgitation, reflux, substernal pain, and recurrent nausea and pain occurring four or more times per year, with duration of less than a day. The evidence does not reflect material weight loss, hematemesis, or melena with moderate anemia, or other symptom combinations productive of severe impairment of health to warrant higher disability ratings during the appeal. Although the Veteran experiences symptoms described above that the Board finds to be productive of considerable impairment of health, the Board also notes that symptoms of material weight loss, hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health are not reported or found. Specifically, September 2019 VA medical records reflect weight gain. In sum, the Board has considered the Veteran's lay assertions regarding severity and finds that the symptoms prior to March 11, 2015 do not support an increased rating in excess of 10 percent, and from March 11, 2015, the symptoms warrant an increased 30 percent rating, however, the preponderance of the evidence is against a higher rating and the claim is denied to that extent. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 3. Entitlement to a disability rating in excess of 10 percent for right knee DJD. 4. Entitlement to a disability rating in excess of 10 percent for left knee DJD. The Veteran contends that the disability ratings for her DJD disabilities of the right and left knees should be rated higher than the assigned 10 percent ratings each. The parties to the October2020 JMPR found that the Board erred when it failed to adequately address the Veteran's July 2019 hearing testimony that she could not walk up and down stairs, bend, sit or stand for too long, or her discussion of needing a knee replacement due to deteriorating knee cartilage. The terms of a Joint Motion will serve as a factor for consideration as to whether or to what extent other issues raised by the record need to be addressed by the Board. See Carter v. Shinseki, 26 Vet. App. 534, 542-43 (2014). Therefore, the crux of the JMPR involved a finding by the parties that the Board had provided inadequate reasons and bases, as discussed above. The Board will provide a discussion on the facts cited by the parties below including the Veteran's testimony during the July 2019 Board hearing. In March 2021, the Board remanded the claim for a new examination was also requested to assess the current nature, extent, and severity of her right and left knee disabilities. As the evidence and legal analysis are similar, the Board will address both knees together. The Veteran's left and right knee disabilities are rated under DC 5260-5003. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). DC 5003 provides that if degenerative arthritis is established by x-rays, then the disability is rated under the appropriate DC for the specific joint limitation of motion. When the rating of a specific joint is noncompensable under the codes pertaining to limitation of motion, a rating of 10 percent is for application for each major joint affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, DCs 5260 and 5261. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Under DC 5260, limitation of flexion of the knee to 45 degrees warrants a 10 percent rating. Limitation of flexion of the knee to 30 degrees warrants a 20 percent rating. Limitation of flexion of the knee to 15 degrees warrants a 30 percent rating. See 38C.F.R. §4.71a, DC 5260. Under DC 5261, a noncompensable rating is warranted for extension of the knee limited to 5 degrees; a 10 percent rating is warranted for extension of the knee limited to 10 degrees; a 20 percent rating is warranted for extension limited to 15 degrees; a 30 percent rating is warranted for extension limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is warranted for extension limited to 45 degrees. Under DC 5256, a 30 percent rating is warranted for ankylosis of the knee with favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating is warranted for ankylosis of the knee with flexion between 10 degrees and 20 degrees. Under DC 5257, a 10 percent rating is warranted for slight knee impairment, that is, recurrent subluxation or lateral instability. A 20 percent rating is assigned for a moderate degree of impairment, and a maximum rating of 30 percent is assigned for severe impairment. Under DC 5258, a 20 percent rating is warranted for cartilage, semilunar dislocated, with frequent episodes of locking, pain, and effusion into the joint. The 20 percent rating is the only rating available under DC 5258. DC 5259 provides that a 10 percent rating is warranted for surgically removed cartilage that is symptomatic. A semilunar cartilage is one of the menisci of the knee joint. A 10 percent rating is also the highest schedular evaluation allowed under DC 5259. Under DC 5262, pertaining to impairment of the tibia and fibula, malunion with slight knee or ankle disability warrants a 10 percent rating; malunion with moderate knee or ankle disability warrants a 20 percent rating; malunion with marked knee or ankle disability warrants a 30 percent rating; and nonunion of the tibia and fibula, with loose motion, requiring brace warrants a maximum 40 percent rating. 38 C.F.R. § 4.71a. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of an increased rating in excess of 10 percent for either a left or right knee disability. The reasons follow. In May 2014, the Veteran was afforded a VA examination to assess her left and right knee disabilities. The Veteran reported that daily knee pain, stiffness, and limitations of walking to 30 minutes or so, total weight bearing (standing plus walking) limited to one hour and had difficulty climbing stairs. She reported flare-ups that impacted the function of the knees as symptoms that were intermittent, brought by overuse for standing, walking or stair climbing and endurance for weight bearing was reduced by pain. The Veteran indicated that she was unable to stand in formation as required by the Reserves. Range of motion testing showed flexion to 130 degrees with no objective evidence of painful and normal extension to 0 degrees without objective evidence of painful motion in the bilateral knees. The Veteran was able to complete repetitive-use testing with at least three repetitions without additional loss of range of motion. Functional impairment was noted as pain on movement and interference with sitting, standing and weight bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue bilaterally. Muscle strength was normal for both knees. Joint stability tests were all normal bilaterally including anterior instability (Lachman test), posterior instability (posterior drawer test), and medial-lateral instability (valgus/varus test). The examiner documented that the Veteran did not have at the time or in the past "shin splints" (medial tibial syndrome), stress fractures, chronic exertional compartment syndrome or other tibial and/or fibular impairment or meniscal conditions or surgical procedures for a meniscal conditions. Imaging studies documented traumatic arthritis but there was no x-ray evidence of patellar subluxation. The Veteran used a brace occasionally as an assistive device as a normal mode of locomotion, although occasional locomotion by other methods may be possible. The examiner noted that the Veteran's knees impacted her ability to work as she was still in the Reserves at the time and was unable to stand for long durations of time in formation. The Veteran was afforded a VA examination in April 2015. The Veteran reported intermittent swelling in either knee, limited standing tolerance for 5 to 10 minutes and similarly limited tolerance for walking activities. It was noted that the Veteran had well-documented degenerative joint disease on plain radiographs with significant chronic knee pain which limited her tolerance for weightbearing activities such as standing, walking, stair climbing, squatting, etc. The Veteran had undergone steroid injections into both knees, which did give some improvement for several months by her report. She denied flare-ups of the knees and reported functional loss as the inability to walk more than 10 minutes, stand more than 10 minutes, and inability to squat or crouch. A physical examination of the knees provided range of motion measurements of flexion of 0 to 100 degrees and extension of 100 to 0 degrees, bilaterally. Range of motion itself did not contribute to functional loss, however, pain was noted on examination, specifically flexion, that caused functional loss. There was evidence of pain with weight bearing and objective evidence of localized tenderness or pain on palpation noted as medial joint line tenderness. There was also objective evidence of crepitus bilaterally. The Veteran was able to perform repetitive-use testing with at least three repetitions without additional loss of function and range of motion. Pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time with pain being the primary limited factor for normal function without specific additional loss of excursion bilaterally. There were additional factors contributing to disability of both knees of disturbance of locomotion, interference with sitting, and interference with standing. Muscle strength testing for the right and left knees were normal with no muscle atrophy. The examiner found that there was no history of recurrent subluxation or lateral instability in either knee. Joint stability testing was performed for both knees, and no joint instability was found with normal Lachman (anterior instability), posterior drawer (posterior instability), valgus pressure (medial instability), and varus pressure (lateral instability) tests. The Veteran did not ever have a meniscus (semilunar cartilage) condition, recurrent patellar dislocation, "shin splits" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or other tibial or fibular impairment. The examiner noted that the Veteran did not use an assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible. The examiner noted functional impact as the Veteran's knees precluding physically demanding occupational function and limits sedentary occupational activities due to impairments in ability to perform activities that require standing or walking for more than 10 minutes at a time. However, the examiner noted that the Veteran's knee disabilities did not specifically preclude occupational activities that are primarily performed while sitting. Most recently, in June 2021, the Veteran was afforded a VA examination to assess her bilateral knee disabilities. The Veteran reported daily knee pain, stiffness, and limitations of walking to 30 minutes or so, total weight bearing (standing plus walking) limited to about one hour and difficulty climbing stairs. She reported flare-ups of the knees of variable frequency and duration with characteristics of increased pain and precipitating factors of use and alleviating factors of rest of moderate severity. The extent of functional impairment she experienced during a flare-up of symptoms was decreased range of motion. The Veteran also reported functional loss or functional impairment was burning pain and weakness with stairs being bad for her and that she was not running anymore. The Veteran did not report a history of instability or recurrent subluxation or a history of frequent effusion of the knees. Range of motion testing showed normal flexion to 140 degrees and normal extension to 0 degrees with pain exhibited on both flexion and extension. Passive range of motion testing was performed and were the same as active range of motion. There was evidence of pain upon weight-bearing, non-weight-bearing, active motion, passive motion, however, it did not result in or cause functional loss. The Veteran was able to perform repetitive-use testing with at least three repetitions without additional loss of function or range of motion bilaterally. The examiner stated that with flare-ups functional capacity was negatively impacted due to pain but there was no anticipated loss of range of motion. There was objective evidence of crepitus and localized tenderness or pain on palpation of the joint or associated soft tissue medially of mild severity. Muscle strength was normal with no muscle atrophy. The examiner concluded that the Veteran did not have ankylosis, recurrent subluxation or persistent instability of either knee. She was noted to require a brace for each knee. She did not have a meniscus (semilunar cartilage) condition, recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, or other tibial or fibular impairment in either knee. The Veteran did not ever have a ligament tear of either knee. Specifically, the examiner stated that the ligament examination was normal bilaterally. The examiner noted that the functional impact of the Veteran's knees as her ability to squat, kneel, and walk long distances as well as use stairs was impaired. In a July 2021 addendum to the June 2021 VA examination report, the examiner clarified that the estimated decreased range of motion for the flare-ups of both knees should be flexion end point of 130 degrees and extension end point to 0 degrees. Based on the evidence, the Board finds that ratings in excess of 10 percent each for the Veteran's right knee and left knee disabilities are not warranted. At the outset, the preponderance of the evidence is against an award for an increased rating at any point of the appeal period for either knee under DC 5256 for ankylosis of the knee; DC 5258 for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint, DC 5259 for symptomatic removal of semilunar cartilage; DC 5262 for impairment of tibia and fibula; or DC 5263 for genu recurvatum as none of these disabilities have been demonstrated upon examinations performed in May 2014, April 2015, and June 2021. The April 2015 and June 2021 examiners documented that the Veteran did not have at the time or ever had a meniscus (semilunar cartilage) condition and the June 2021 examiner specifically found that there was no ankylosis. 38 C.F.R. § 4.71a, DCs 5256, 5258, 5259, 5262, 5263. The Board also finds that the preponderance of the evidence of record is against higher or an additional separate rating for the service-connected right and left knee disabilities under other DCs. The preponderance of the evidence is against a finding that the Veteran exhibited recurrent subluxation or lateral instability in the right knee, at any point in the appeal period. Specifically, the examiners found no subluxation or instability during the May 2014, April 2015, and June 2021 examinations. The VA examiners tested anterior instability (Lachman test); posterior instability (posterior drawer test); medial-lateral instability (varus and valgus pressure), and all of these resulted in negative findings. Thus, three, different medical professionals performed more than one stability test, which is indicative of a detailed clinical examination to determine if the Veteran had instability. In other words, it is not a matter of the examiner making a cursory conclusion that there is no instability, but rather the examiner laying out the multiple stability testing that was performed and the conclusion reached for each test. These clinical findings cover a seven-year period and all of the clinical findings are consistent with each other. This is not a situation where one medical professional found that there was instability, but another did not. The examiners all found that the Veteran's right and left knees did not have clinical findings of instability. In Jandreau, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when... lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The issue of whether the Veteran's perceived symptom of bilateral knee instability is competent and sufficient to establish that she has actual instability of the knees sufficient to warrant separate disability ratings under Diagnostic Code 5257 is analogous to the situation described in Jandreau. In this case, the Veteran has described her perception of bilateral knee instability. However, numerous medical professionals have tested her knees for instability during the pendency of the appeal and none has found even slight instability on anterior, posterior, medial, or lateral stability testing. Because the Veteran's perceived symptom of bilateral knee instability has repeatedly not been demonstrated or confirmed on clinical testing by numerous independent medical professionals, her lay statements are insufficient to establish the presence of anterior, posterior, medial, or lateral instability sufficient to warrant separate disability rating for either knee. In English v. Wilkie, 30 Vet. App. 347 (2018), the Court held that the Board cannot find objective medical evidence categorically more probative than lay evidence without explaining why that is the case. To be clear, the Board finds the objective medical evidence more probative than the Veteran's reports of perceived bilateral knee instability for two reasons. First, the clinical findings by the May 2014, April 2015, and June 2021 VA examiners involved three and four forms of stability testing, and none of the examinations demonstrated bilateral knee instability. The thorough, repeated stability testing, which did not reveal instability, supports the conclusion that the Veteran's perceived knee instability is not due to anterior, posterior, medial, or lateral knee joint instability. Second, the three examinations conducted between May 2014 and June 2021a seven-year periodwere performed by three, different medical professionals. Each performed joint stability testing for the right and left knees, and each documented the knees were stable to stability testing. The internal consistency among the three independent examiners bolsters the conclusion that their findings of no bilateral knee joint instability were accurate. It is for these reasons that the Board finds the clinical findings by medical professionals outweigh the Veteran's allegation of bilateral knee instability, and the preponderance of the evidence is against finding that the Veteran has instability in either knee to warrant a separate rating under Diagnostic Code 5257 for instability of the knees. The Board finds that the Veteran's left knee has manifested in reduced range of motion with flexion, at worst, at 100 degrees during the April 2015 VA examination, including additional limitations during flare-ups and with repetitive use. The Board acknowledges the Veteran's lay reports of symptoms, including such reported during the July 2019 Board hearing, and that there was functional loss due to weakness, pain with motion, pain with weightbearing, repetitive use, pain during flare-ups, and pain during repetitive use over time, which affect the Veteran's ability to stand for long durations, walk downstairs, squat or kneel, and walk distances, among other things. While the Veteran reported that she would need knee replacements due to deteriorating cartilage, the evidence of record does not reflect that a knee replacement has been performed in either knee or reflect deteriorating cartilage. Specifically, the June 2021 VA examination report shows that the examiner found no meniscus (semilunar cartilage) condition, recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, or other tibial or fibular impairment in either knee. The examiner documented that the ligament examination was normal, bilaterally, and there was no ligament tear of either knee. Even considering the Veteran's reports of symptoms and noted functional loss, the preponderance of the evidence is against a finding that the manifestations of either her right or left knee disabilities have been so disabling as to result in limitation of motion more nearly approximating flexion limited to 30 degrees, which would warrant a rating in excess of 10 percent rating under DC 5260. To the extent that the limitation of range of motion and functional loss due to pain and other factors delineated in 38 C.F.R. §§ 4.40 and 4.45; to include with repeated use or during flare-ups, has not been sufficiently addressed in prior VA examinations, the Board extrapolates the findings of the July 2020 VA examination to the duration of the appeal. Hence, even with consideration of these factors, the record presents no basis for the assignment of a rating in excess of 10 percent for the right or left knee under DC 5260. See DeLuca, 8 Vet. App. at 204-7. 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.59, 4.71a, DC 5260. The Board also finds that a separate compensable rating is not warranted during the appeal period based upon limitation of extension of the right knee. In the reports of the VA examinations of record, the Veteran has not demonstrated limitation of extension in excess of 0 degrees during the appeal period. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to weakness, pain with motion, pain with weightbearing, repetitive use, pain during flare-ups, and pain during repetitive use over time, which affect the Veteran's ability to stand for long durations, walk downstairs, squat or kneel, and walk distances, among other things. However, even considering the Veteran's reports of symptoms and noted functional loss, the weight of the evidence of record does not support manifestations of her left knee disability that result in extension limited to 10 degrees or more, which would warrant a separate compensable rating under DC 5261. 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.59, 4.71a, DC 5261. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. DC 5257 is one of the diagnostic codes that was amended. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021 and both the former and amended rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, under the former version of DC 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. As of February 7, 2021, under the amended criteria for DC 5257, for recurrent subluxation or instability, a 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for one of the following: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. 38 C.F.R. § 4.71a, DC 5257. Additionally, as of February 7, 2021, under the amended criteria for DC 5257, for patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. 38 C.F.R. § 4.71a, DC 5257. The Board finds that the preponderance of the evidence is against separate rating under DC 5257 at any point during the period on appeal. From February 7, 2021, the Veteran's symptoms do not meet the criteria for a compensable rating under the amended version of DC 5257. The Board notes that the Veteran condition is not diagnosed as a sprain or a ligament tear. The Board has found above that the preponderance of the evidence is against a finding of recurrent subluxation or lateral instability in the left or right knee at any point in the appeal period under the former version of DC 5257. As such, there is no finding of recurrent instability and the criteria for a 10 percent rating under the revised DC 5257 is not for application. Under the former DC 5257 criteria, the Veteran does not warrant a compensable rating because the medical evidence, which is probative, fails to establish clinical findings of recurrent subluxation or lateral instability on each of the examinations of record. All examination reports of record which show testing for lateral instability and recurrent subluxation were normal in the right and left knees. 38 C.F.R. §§ 4.3, 4.71a, DC 5257 (2012-2021). In deciding the Veteran's increased rating claim, the Board has considered the determination in Hart v. Mansfield, 21 Vet. App. 505 (2008), and whether the Veteran is entitled to increased evaluations for separate periods based on the facts found during the appeal period. The evidence of record supports the conclusion that the Veteran is not entitled to additional increased compensation at any time within the appeal period. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for ratings in excess of 10 percent each for degenerative joint disease of the left knee and right knee. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable and the claims are denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 4.3; Gilbert, 1 Vet. App. 49. 5. Entitlement to a compensable disability rating for tension headaches. The Veteran contends that the disability rating for her headaches disability should be rated higher than the assigned noncompensable rating. In the October 2020 JMPR, the parties had found that the Board erred when it failed to provide an adequate statement of reasons or bases for this conclusion in light of the Veteran's July 2019 hearing testimony that she had headaches three times a week, each lasting a day or two, and had just been to the emergency room due to a headache four days prior. Moreover, the parties agreed that on remand, the Board shall also obtain the emergency room treatment records related to the July 2019 emergency treatment as testified during the Board hearing and ensure that other outstanding VA treatment records are associated with the Veteran's file. The terms of a Joint Motion will serve as a factor for consideration as to whether or to what extent other issues raised by the record need to be addressed by the Board. See Carter, 26 Vet. App. at 542-43. Therefore, the crux of the JMPR involved a finding by the parties that the Board had provided inadequate reasons and bases, as discussed above. The Board will provide a discussion on the facts cited by the parties below including the Veteran's testimony during the July 2019 Board hearing. In March 2021, the Board remanded the claim to obtain outstanding VA treatment records, including the July 2019 emergency treatment as testified during the Board hearing. A new examination was also requested to assess the current nature, extent, and severity of her tension headaches disability. The rating for the Veteran's headache disability has been assigned by analogy under DC 8199-8100. A noncompensable rating is assigned for migraine headaches with less frequent attacks. A 10 percent rating is assigned for migraine headaches with characteristic prostrating attacks averaging one in two months over last several months. A 30 percent rating is assigned for migraine headaches with characteristic prostrating attacks occurring on an average once per month over the last several months. A maximum 50 percent rating is assigned for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. The rating criteria do not define "prostrating," nor has the U.S. Court of Appeals for Veterans Claims. See Fenderson v. West, 12 Vet. App. 119 (1999) (quoting DC 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). According to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of a compensable rating for tension headaches. The reasons follow. In a December 2013 headaches questionnaire in conjunction with the Veteran's claim for Social Security Administration (SSA) benefits, she stated that her headaches lasted a day or two and occurred about 8 to 12 times or more a month. The Veteran stated that the headaches caused nausea, vomiting, neck pain, throat pain or blurred vision, and prevent her from driving, cooking, cleaning, or watching television. She indicated that she used ibuprofen or over the counter pain killers, which was "sometimes" effective in stopping her headaches and took about a half hour or "sometimes longer" to work. During the VA examination in May 2014, the Veteran reported that her headaches had improved since February 2012 when she was put on medications for anxiety and depression. She stated that the headaches remained similar in character but significantly less frequent and specifically indicated that she did not have a severe headache in months at the time of examination. She described headaches consistent with tension headaches occurring about three times per month, manageable with ibuprofen and not prostrating. The Veteran was very adamant about her headaches being a result of her sinus conditions and infections and stated that the headaches only occurred in tandem with an infection of her sinuses. Symptoms of headache pain were noted as pulsating or throbbing head pain on both sides of the head. The Veteran experienced non-headache symptoms associated with headaches listed as sensitivity to light and sound. The duration of typical head pain was noted as less than 1 day at both sides of the head. The examiner concluded that the Veteran did not have characteristic prostrating attacks of migraine headache pain. The functional impact of the headache condition as reported by the Veteran was that her headache pain kept her from being able to perform drills in the reserves because she was unable to maintain focus due to the pain and only wanted to "lay down and cover her ears." A March 2015 VA medical record reflects that the Veteran called with complaints of having a vomiting issue and not being able to keep anything down. She reported having a headache of a 10 out of 10 severity and that her headache was bad because the pain was in her eyes. In a June 2015 VA medical record, it was stated that Ondansetron previously prescribed caused severe headaches. The Veteran also complained of headaches in February 2016 and May 2016. In a May 2018 emergency room VA medical record, the Veteran stated that she had a rapid onset of headache behind her eyes at work. A history of migraine headaches of two to three days of headaches per week was noted. The headache was noted to be "a fairly typical headache" for her, but sometimes they were worse. The headaches were noted to be debilitating to her and the medical professional noted that would be considered whether she was also experiencing medication overuse headache. Her headache almost completely resolved without further treatment in the emergency room. The Veteran was seen again in the VA emergency room in November 2018 for a complaint of headache for the preceding three days. She indicated that the pain started on the left side and migrated over a couple days to the right side with a slow onset. The Veteran stated that ibuprofen helped the pain but did not completely resolve it and her pain was similar to her chronic headaches. She reported that she had several episodes that have been this persistent previously and that she vomited, which was not typical. In a July 2019 VA medical record, four days prior to the Board hearing, the Veteran reported a headache the previous night on her right temple and that her neck tightened up. She stated that she used heat and ibuprofen and threw up in the morning. The medical professional's treatment plan was to discontinue use of all nonsteroidal anti-inflammatory drugs (NSAIDs) because of stomach issues, to which the Veteran voiced understanding though Tylenol did not help her headaches. Zolmitriptan for migraines was renewed and the Veteran said that it worked well. As mentioned above, during the July 2019 Board hearing, the Veteran reported headaches about three times a week that usually lasted a day or two until she would go to the emergency room if they lasted more than two days. She stated that the headaches caused the muscles in her neck to tighten up and she had to plug her ears because of the sounds of ringing. She indicated that she would have to take hot showers because of the tension. In August 2019, the Veteran presented to the VA emergency room for headache that was behind her left eye which began that day. She stated that her ears felt "clogged" She had a normal neurologic exam and no temporal artery tenderness. The Veteran declined computed tomography (CT) imaging stating that she believed she has had too much radiation exposure and her pain was markedly improved with Toradol and Zofran. An examiner in June 2021 noted that the Veteran had current symptoms of headaches as neck tension and would treat with an ice pack on the neck or head and Tylenol. The Veteran reported having constant head pain, pulsating or throbbing, and pain on both sides of the head, with pain lasting less than one day. She experienced non-headache symptoms associated with headaches including nausea and sensitivity to light and sound. The examiner noted that the Veteran did not have characteristic prostrating attacks of migraine headache pain or non-migraine headache pain with less frequent attacks. The examiner documented that the Veteran did not have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. Further, the examiner found that the Veteran's headache condition did impact her ability to work during acute headache pain as her ability to concentrate and perform physical exertion is impaired. As the Veteran's headaches have not shown to manifest with characteristic prostrating attacks averaging at least one in two months over several months at any point in the appeal period, an increased compensable rating is not warranted. The May 2014 VA examiner noted that the Veteran did not have characteristic prostrating attacks of migraine headache pain. Further, the June 2021 examination reports show that while the Veteran experienced characteristic prostrating attacks of migraine headache pain or non-migraine headache pain with less frequent attacks, she did not have very prostrating and prolonged attacks of migraines/non-migraine pain productive os severe economic inadaptability. The Veteran was not shown to have experienced prostrating attacks as defined as "utter physical exhaustion or helplessness" or "extreme exhaustion or powerlessness" at any point of the appeal period. The record reflects that the Veteran sought medical treatment for headaches during the appeal period, as noted above, however, were not shown to be characteristic of prostrating attacks. At worst, the Veteran reported a 10 out of 10 severity headaches in March 2015, however, indicated that it was bad because the pain was in her eyes and did not report that it resulted in exhaustion or helplessness, nor contend that it was a characteristic prostrating attack. The Veteran's headaches were noted to be "debilitating to her" in a May 2018 VA emergency room record, which she reported a rapid onset of headache behind her eyes at work, however, such headache almost completely resolved without further treatment in the emergency room. The Veteran was seen in July 2019 and August 2019 for headaches, including the latter behind the left eye and resulting in a feeling that her ears were "clogged." As the Veteran has reported during the July 2019 Board hearing, her headaches have shown to result in tension / tightening of the neck muscles and ringing or clogging of the ears in most instances. The Board has considered the Veteran's testimony that she had headaches three times a week, each lasting a day or two. The Veteran does not report that such headaches were characteristic prostrating attacks, for example, she indicated that hot showers would relieve tension caused by her headaches. The worst headaches seem to have been due to pain in or around the eyes, which have not resulted in characteristic prostrating attacks. Regardless, the documented instances of such headaches of a severity which required the Veteran to seek medical treatment were not averaging at least one in two months over several months at any point in the appeal period. Therefore, the preponderance of the evidence is against a showing of prostrating attacks at any point during the appeal period. For the above reasons, the Board finds that the preponderance of the evidence is against entitlement to a compensable disability rating for migraine headaches throughout the appeal period and the claim for a compensable rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 4.3; Gilbert, 1 Vet. App. 49. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cheng, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.