Citation Nr: 21076286 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 17-13 832 DATE: December 23, 2021 ORDER For the entire period on appeal, beginning December 20, 2010, an initial rating of 10 percent, but no higher, for residuals of a traumatic brain injury (TBI) is granted. For the entire period on appeal, beginning December 20, 2010, an initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted. For the entire period on appeal, beginning December 20, 2010, an initial rating of 50 percent, but no higher, for migraine headaches is granted. FINDINGS OF FACT 1. For the entire period on appeal, the objective evidence shows that the Veteran's residuals of TBI were rated as "1" in one facet; the residuals of TBI were not shown to be rated as "2," "3," or "total" in one or more facets. 2. For the entire period on appeal, the Veteran's PTSD symptoms most nearly approximated occupational and social impairment with deficiencies in most areas, but the evidence did not more nearly approximate total social and occupational impairment. 3. For the entire period on appeal, the Veteran's migraine headache symptoms most nearly approximated very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for an initial rating of 10 percent, but no higher, for residuals of TBI have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8045 (2021). 2. For the entire period on appeal, the criteria for a rating of 70 percent, but no higher, for PTSD, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2021). 3. For the entire period on appeal, the criteria for a 50 percent rating for migraine headaches have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.130, DC 8100 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from February 2003 to June 2004, and from May 2006 to October 2007. She also had Reserve Component service, including periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for a TBI (rated 0 percent disabling) and PTSD (rated 30 percent disabling), effective December 20, 2010. In a February 2017 rating decision, during the pendency of this appeal, the RO awarded a separate 30 percent rating for migraine headaches associated with TBI, effective January 9, 2016, and increased the rating for PTSD from 30 to 50 percent, also effective January 9, 2016. To the extent that less than the maximum available benefit for a schedular rating was awarded and the separate and increased ratings were not awarded for the entirety of the claims period, the claims remain before the Board. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35 (1993). The Veteran testified at a July 2021 Board virtual hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the claims file. The Board considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. Although the Veteran reported having some occupational impairment related to her service-connected disabilities, the record does not indicate that these issues resulted in unemployment during the period on appeal. Importantly, neither the Veteran nor her representative have indicated that the Veteran is unable to maintain substantially gainful employment due to her service-connected disabilities. The Board therefore finds that Rice is inapplicable, and a TDIU request has not been inferred. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (applying this concept to initial ratings). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where a veteran is diagnosed with multiple disabilities of the same body part/system, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through the senses. See Layno, 6 Vet. App. at 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. 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 an initial rating in excess of 30 percent prior to January 9, 2016, and in excess of 50 percent thereafter. 2. Entitlement to an initial compensable rating for residuals of a TBI. 3. Entitlement to an initial rating in excess of 30 percent for migraine headaches. The Veteran is seeking an increased rating for residuals of a TBI. He is currently in receipt of service connection, in pertinent part, for the following disabilities: (1) residuals of a TBI, rated 0 percent disabling, under 38 C.F.R. § 4.124a, DC 8045, applicable to residuals of TBI; (2) PTSD, rated 30 percent disabling prior to January 9, 2016, and in excess of 50 percent thereafter, under 38 C.F.R. § 4.130, DC 9411, applicable to PTSD; (3) migraine headaches, rated 30 percent disabling from January 9, 2016, under 38 C.F.R. § 4.124a, DC 8100, applicable to migraine. Each of these disabilities is a residual of TBI. Therefore, the Board will consider them both together and separately in order to assign the highest possible combined rating. A. Summary of the Relevant Evidence A March 2005 VA treatment record indicated that the Veteran was very fatigued and had no interest in activities. She was short-tempered, felt like she had no control of her temper, and was verbally abusive toward her significant other. An April 2005 VA treatment record indicated that the Veteran's family told her that she had changed after her first deployment. She felt unmotivated to do anything other than sit around her apartment. She avoided her family, friends, and social situations. If she did go out to a restaurant, she would sit with her back to the wall so that she could watch the comings and goings of other patrons. She reported always feeling tense and having difficulty sleeping if she was alone in her apartment. She admitted to keeping a gun by her bed for protection. She was easily startled by noises and always felt that there may be "someone there," even when no one was present. She saw shadows, but reported to audiovisual hallucinations. Her sleep was often poor; however, she often felt like doing nothing other than sleeping during the day. She found herself "aggressive," which she described as being verbally abusive to her significant other. She denied being violent. She described ruminating and worrying all the time about multiple things. She had been forgetful and felt that her mind went blank. She had no suicidal ideation or homicidal ideation. Her significant other reported that the Veteran was always angry. The Veteran and her significant other had been involved since October 2004, but their relationship had been adversely affected due to the Veteran's verbal abuse of her significant other. She had recently quit her job because her employer kept cutting her hours. On examination, the Veteran was mildly to moderately depressed. She had difficulty concentrating when asked to do serial sevens. Her insight and judgment were described as "fair." The Veteran was frustrated by her depression, anxiety, and aggression, and had taken measures to not put herself in situations where she may lose control. An August 2005 VA PTSD examination report indicated that the Veteran had chronic sleep impairment. She had intrusive memories of Iraq that were upsetting and bothersome, and reported physiological reactivity in response to triggers that reminded her of Iraq, such as loud noises. She felt more irritable and angry, lost her temper easily, and had pulled out her gun in moments of anger. She reported lapses in memory about some of the details. She endorsed problems with concentration and focus. She reported pushing people away emotionally, and begin less affectionate and less likely to share her feelings with others. She felt more detached. She endorsed an exaggerated startle response and hypervigilance. She checked doors and locks frequently, and at one point was sleeping with a gun. The symptoms described occurred constantly. The Veteran was also diagnosed with depression, with symptoms of depressed mood, poor energy, variable appetite, poor interest and concentration, and a feeling of helplessness. She reported having a good relationship with her mother and her siblings, but was estranged from two brothers. She was single. She did not feel like doing anything all day, stayed at home, and was not involved in any social activities or hobbies. The VA examiner noted that the Veteran had a persistent, markedly diminished interest or participation in significant activities, including all friends and hobbies. The Veteran also had a persistent feeling of detachment or estrangement from others, including her family. She had symptoms of increased arousal, including difficulty sleeping, persistent and easy irritability or outbursts of anger, including pulling out her weapon. She had also had a persistent, exaggerated startle response with unexpected loud noises, and persistent hypervigilance, such that any noise interfered with her sleep. Her appearance, hygiene, thought processes, and behavior were appropriate. Her affect and mood were abnormal with depressed mood, although the depression did not affect her ability to function independently and effectively. Panic attacks were absent, and there was no history or evidence of delusions or hallucinations. She had no obsessional rituals. Her memory was within normal limits, and she had no suicidal ideation or homicidal ideation. The VA examiner opined that the Veteran occasionally had some interference in performing activities of daily living because of lack of motivation and depression. The VA examiner also opined that the Veteran had difficulty establishing and maintaining effective work and social relationships because of emotional detachment and lack of trust. The VA examiner concluded that the Veteran did not pose a threat of persistent danger or injury to herself or others. A June 2010 VA treatment note indicated that the Veteran's affect was restricted and her mood was anxious. A July 2010 VA treatment note indicated that the Veteran's affect was restricted. A November 2010 VA psychology note indicated that the Veteran was struggling in her current relationship in her ability to be vulnerable. She continued to struggle a little with safety in public situations. In March 2011, the Veteran was afforded a VA PTSD examination. The Veteran was single, and living with family. She described her current symptoms as aggressiveness, hypervigilance, depression, panic attacks, anxiety, and sleep impairment. The VA examiner described the symptoms as severe and constant. The Veteran reported having low energy, isolating herself socially, taking two years off from civilian work because she "just couldn't be out," and being fatigued. She reported that she did not trust herself to be in a relationship because she was so irritable over silly things. She described an incident in which she was playing darts with someone who cheated, so she went for her gun. The Veteran indicated that she had "really close" relationships with her mother and five siblings. However, she isolated herself from other people, including old friends. The Veteran indicated that she had been working for the past one and a half years as a contractor for the military, and she had great relationships with her supervisor and co-workers. The Veteran reported that she was very irritable, but that she did not lose control. She reported having an exaggerated startle response and difficulty concentrating. On examination, her appearance, hygiene, and behavior were appropriate. Her affect and mood showed anxiety. She reported that she was always depressed and anxious, but had been feeling more anxious to the point of shaking in recent weeks, for no apparent reason. Her communication and speech were within normal limits. She showed impaired attention and/or focus, and reported being very easily distracted. She had more than one panic attack per week, involving a racing heart, shaking hands, and sweating. She showed signs of suspiciousness. There was no history or current observation of delusions. However, a hallucination history was present occasionally, including sometimes seeing a black figure trying to hold her down. The last time she had this hallucination was about a month prior. At the time of the examination, no hallucination was observed. Obsessive compulsive behavior was present, but was not severe enough to interfere with routine activities. The Veteran reported that she had "to have things in a very particular way; I can't have something moved or I have to put it back in its place. I have to check all the windows [are] locked before I leave the house, when I return, and once or twice before I got to bed." Her memory was impaired to a mild degree, such that she would forget names, directions, and recent events. The VA examiner noted that the Veteran did not have difficulty performing activities of daily living. The VA examiner opined that the Veteran's PTSD symptoms were best described as causing occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally functioning satisfactorily with routine behavior, self-care, and normal conversation. In March 2012, the Veteran was afforded a VA TBI examination. As to the facet of memory, attention, concentration, and executive functions, the VA examiner opined that the Veteran had a complaint of mild memory loss, attention, concentration, or executive functions, but without objective evidence on testing. The judgment, social interaction, orientation, motor activity, visual spatial orientation, neurobehavioral effects, communication, and consciousness facets were all normal. The Veteran had subjective symptoms that did not interfere with work, instrumental activities of daily living, work, or close family relationships, including mild or occasional headaches and mild anxiety. The VA examiner opined that these abnormal complaints were more likely due to her major depression and PTSD, and that there was no current significant residual from the TBI. No testing was performed. In January 2016, the Veteran was afforded a VA headaches examination. She stated that she began to develop problems with migraine headaches around the time of her TBI. She experienced headache pain which was described as pulsating or throbbing head pain, on both sides of the head, and worsening with physical activity. She experienced non-headache symptoms associated with the headaches, including nausea, sensitivity to light and sound, and changes in vision (such as scotoma, flashes of light, tunnel vision). The typical headache was treated by taking painkillers and had a duration of less than one day. The VA examiner opined that the Veteran had characteristic prostrating attacks of migraine headache pain more frequently than once per month. The VA examiner further opined that the Veteran had very frequent prostrating and prolonged attacks of migraine headache pain. The Veteran's headache condition affected the Veteran's ability to work because it affected her workflow, motivation, concentration, and social interaction. In January 2016, the Veteran was afforded a VA TBI examination. As to the facet of memory, attention, concentration, and executive functions, the VA examiner opined that the Veteran had a complaint of mild memory loss, attention, concentration, or executive functions, but without objective evidence on testing. The Veteran reported some decreased short-term memory, as well as decreased concentration at work. The judgment, social interaction, orientation, motor activity, visual spatial orientation, neurobehavioral effects, communication, and consciousness facets were all normal. The Veteran had subjective symptoms that did not interfere with work, instrumental activities of daily living, work, or close family relationships, including mild or occasional headaches and mild anxiety. No diagnostic testing was performed. The VA examiner opined that the Veteran's TBI affected the Veteran's ability to work because it affected her workflow, motivation, concentration, and social interaction. In January 2016, the Veteran was afforded a VA PTSD examination. The VA examiner opined that it is possible to differentiate what symptoms are attributable to the Veteran's PTSD versus TBI. Specifically, the VA examiner noted that the Veteran denies experiencing any problems from the TBI other than occasional migraines, once or twice a month, self-rated as a 9/10 in severity. During these migraines, she takes ibuprofen and stays in bed until the migraine passes. The remainder of her symptoms described in this examination report were attributed to the Veteran's PTSD diagnosis. The VA examiner opined that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran was making efforts to become more social, including contacting previous friends and some family members through Facebook. She and her partner of five years attended her partner's children's athletic games. She had plans to go bowling with her co-workers in two weeks. She received positive performance evaluations at work. She was noted to have irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects, hypervigilance, an exaggerated startle response, and sleep disturbance. She also had symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. Her affect was anxious and sad, and her mood was anxious, emotional, and depressed. During the July 2021 Board hearing, the Veteran testified that she has migraines once or twice a month, lasting one to two minutes. She stated that the migraines typically were alleviated by taking a painkiller within a minute or two. The migraines were overwhelming at first, because of light sensitivity. She would have to lay down and could not do anything due to the migraines. The Veteran stated that she had to leave work and go home a couple of times if she did not have the painkillers available. The Veteran testified that her short-term memory was very bad. She sometimes could not remember what she had done a few minutes earlier and had to rely on the people around her for help. She had to write everything down at work to aid her memory. She worked in logistics, in both office and warehouse settings. She also relied on a co-worker to help her remember things. She reported minor problems with long-term memory, stating that there were some things that people said happened but she did not remember. The Veteran reported experiencing chronic sleep impairment, panic attacks, anxiety, chronic depression, and suspiciousness. She had been working at the same place for 11-12 years, and had good relationships at work. She tried to alleviate stress as much as possible, such that she isolated herself from some family members. She had a concealed weapons permit, but did not carry a weapon because she did not trust what she would do to someone else due to her quick temper. She stated that she had obsessive-compulsive tendencies and described herself as like a verbal abuser. B. Applicable Laws and Regulations for Residuals of TBI Under DC 8045, there are three main areas of dysfunction listed that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Adjudicators are to rate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Id. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Adjudicators are to rate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, they are to separately rate any residual with a distinct diagnosis that may be rated under another Diagnostic Code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Id. Therefore, as discussed herein, the Board has separately rated the Veteran's diagnosed migraine headaches. Adjudicators are to rate emotional/behavioral dysfunction under 38 C.F.R. § 4.130 (Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, they are to evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Id. Here, the Veteran has a diagnosis of a mental disorder; therefore, such symptoms are evaluated separately under 38 C.F.R. § 4.130, DC 9411. Adjudicators are to rate physical (including neurological) dysfunction based on the following list, under an appropriate Diagnostic Code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. Id. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, adjudicators are to rate under the most appropriate Diagnostic Code. Adjudicators are to rate each condition separately, as long as the same signs and symptoms are not used to support more than one rating, and combine under § 4.25 the ratings for each separately rated condition. The rating assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the rating for a single condition for purposes of combining with other disability ratings. Id. The table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. Adjudicators are to assign a 100-percent rating if "total" is the level of evaluation for one or more facets. If no facet is rated as "total," adjudicators are to assign the overall percentage rating based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent rating if 3 is the highest level of evaluation for any facet. Id. The rating assigned is based upon the highest level of severity for any facet of cognitive impairment and other residuals of TBI not otherwise classified as determined on examination. Only one rating is assigned for all the applicable facets. A rating evaluation is not warranted unless a higher level of severity for a facet is established on examination. Physical and/or emotional/behavioral disabilities found on examination that are determined to be residuals of traumatic brain injury are rated separately. As an initial matter, the Board notes that the March 2012 and January 2016 VA TBI examination reports are the only medical evidence of record regarding the severity of the Veteran's TBI. These examinations are largely consistent in their findings. The March 2012 and January 2016 VA TBI examination reports are adequate and highly probative, as they are based on an examination of the Veteran and review of the record, include a detailed discussion of the Veteran's various TBI symptoms and residuals, and provide an explanation of why such symptoms are attributable to the diagnosed TBI versus PTSD. Based on the March 2012 and January 2016 VA TBI examination report, the Veteran's memory, attention, concentration, and executive functions facet is assigned a level of severity of "1," based on evidence of mild memory loss, attention, concentration, or executive functions, but without objective evidence on testing. Specifically, the Veteran reported some decreased short-term memory, as well as decreased concentration at work. A severity level of "0" has been assigned for the following facets: judgment ("normal"); social interaction ("routinely appropriate"); orientation ("always oriented to person, time, place, and situation); motor activity ("normal"); visual spatial orientation ("normal"); communication ("able to communicate by and comprehend spoken and written language"); and consciousness ("normal"). A severity level of "1" is assigned for neurobehavioral effects, based on evidence of one or more neurobehavioral effects that do not interfere with workplace or social interaction. Specifically, the January 2016 VA examination report indicated that the Veteran reports some decrease in motivation and lack of cooperation, as well as an increase in irritability and impulsivity. A severity level of "1" is assigned for subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships. Specifically, the January 2016 VA examination report indicated that the Veteran reported experiencing recurrent migraine headaches associated with her TBI. In addition, the March 2012 VA examination report indicated that the Veteran experienced symptoms of mild or occasional headaches and mild anxiety. Based on these assigned levels for each facet, the Board finds that the Veteran's residuals of TBI more nearly approximate an initial rating of 10 percent for the entire period on appeal. In this regard, the evidence indicates that level of severity "1" as the highest facet, thus warranting a 10 percent rating. The Board specifically notes that this is based on the evidence of a "1" level of severity for the memory, attention, concentration, and executive functions facet, the symptoms of which do not overlap with the symptoms considered for any other assigned rating. In so finding, the Board emphasizes that DC 8045 explicitly states that "symptoms [of cognitive impairment] may fluctuate in severity from day to day." For these reasons, the Board finds that the weight of the evidence supports an initial rating in of 10 percent for the entire period on appeal. C. Entitlement to an initial rating in excess of 30 percent for PTSD prior to January 9, 2016, and in excess of 50 percent thereafter. The Veteran is in receipt of a 30 percent initial rating for PTSD prior to January 9, 2016, and a 50 percent rating thereafter, under 38 C.F.R. § 4.130, DC 9411. She contends that higher ratings are warranted for PTSD for the entire initial rating period on appeal. The Veteran's PTSD is rated under the general rating formula for rating mental disorders pursuant to 38 C.F.R. § 4.130, DC 9411. Under such formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as de-pressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. A total schedular rating of 100 percent is warranted when the disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of mental and personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). Here, the RO certified the Veteran's appeal to the Board after August 4, 2014; therefore, the PTSD claim is governed by DSM 5 and the GAF scores are not relevant for consideration. See Golden v. Shulkin, 29 Vet. App. 221, 225-26 (2018) (holding that the Board errs when it uses GAF scores to assign a psychiatric rating in cases where DSM-5 applies). When evaluating mental health disorders, the factors listed in the Rating Schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; the analysis should not be limited solely to whether a veteran exhibited the symptoms listed in the Rating Schedule. Rather, the determination should be based on all of a veteran's symptoms affecting his or her level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The lists of symptoms under the Rating Schedule are meant to be examples of symptoms that would warrant the disability evaluation but are not meant to be exhaustive. Id. Based on review of the evidence, both lay and medical, the Board finds that the Veteran's PTSD symptoms have most nearly approximated occupational and social impairment with deficiencies in most areas for the entire period on appeal. The evidence reflects that the Veteran has experienced symptoms of difficulty in establishing and maintaining effective relationships. See April 2005 VA treatment record (noting Veteran avoided her family, friends, and social situations and her relationship with her significant other was adversely affected by her verbal abuse); August 2005 VA PTSD examination report (reporting people away emotionally, and begin less affectionate and less likely to share her feelings with others; noting difficulty establishing and maintaining effective work and social relationships because of emotional detachment and lack of trust); November 2010 VA psychology note (indicating that she was struggling in her current relationship in her ability to be vulnerable); March 2011 VA examination report (reporting isolating herself socially, taking two years off from civilian work because she "just couldn't be out," isolating herself from non-family members, and not trusting herself to be in a relationship due to her irritability); July 2021 Board hearing transcript (testifying that she tried to alleviate stress as much as possible, such that she isolated herself from some family members). In addition, the evidence reflects symptoms of impaired impulse control, such as unprovoked irritability with periods of violence. See April 2005 VA treatment record; August 2005 VA PTSD examination report; March 2011 VA PTSD examination report; January 2016 VA PTSD examination report; July 2021 Board hearing transcript. The evidence also reflects the presence of obsessional rituals which interfere with routine activities. See March 2011 VA examination report (reporting obsessional rituals that did not interfere with routine activities); July 2021 Board hearing transcript. Finally, the evidence reflects that the Veteran has experienced symptoms of depressed mood, anxiety, panic attacks, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. See January 2016 VA PTSD examination report. For these reasons, the Board finds that the Veteran's PTSD symptoms have more nearly approximated occupational and social impairment with deficiencies in most areas throughout the rating period on appeal, warranting a 70 percent rating. However, a rating higher than 70 percent is not warranted because the evidence does not reflect that the Veteran's PTSD has caused total occupational and social impairment. There is no evidence of disorientation to time or place, persistent delusions or hallucinations, persistent danger of hurting self or others, grossly inappropriate behavior, gross impairment in thought processes or communication, intermittent inability to perform activities of daily living, or memory loss for close relatives, own occupation, or own name. Throughout the period on appeal, the Veteran has maintained a relationship with her family and has held multiple jobs for extended periods of time, including her current full-time employment. While the Veteran has reported symptoms of memory loss, the Board notes that those symptoms are contemplated by the 10 percent rating awarded herein for a TBI under DC 8045, and cannot be considered in assigning ratings for multiple disabilities. Furthermore, the Veteran's reported mild memory loss and impaired concentration do not rise to the levels of disorientation to time or place, gross impairment in thought processes, or memory loss for names of close relatives, own occupation, or own name, as is required for a 100 percent rating. In addition, the Board notes that while the March 2011 VA examination report indicates that the Veteran experienced a history of occasional hallucinations, the record does not reflect the presence of persistent delusions, as is required for a 100 percent rating. The Board notes further that a higher rating of 100 percent based on total occupational and social impairment generally requires symptoms severe enough to severely distort the individual's perception of reality, which is not shown by the record. For these reasons, total occupational and social impairment is not demonstrated by the record, and a 100 percent rating for the Veteran's PTSD is not warranted. D. Entitlement to a separate compensable rating for migraine headaches prior to January 9, 2016, and in excess of 30 percent thereafter. The Veteran is in receipt of a 30 percent rating for migraine headaches from January 9, 2016, under 38 C.F.R. § 4.124a, DC 8100, applicable to migraine. She contends that a separate compensable rating for headaches is warranted for the period prior to January 9, 2016, and a rating in excess of 30 percent thereafter. Under DC 8100, a 50 percent rating is warranted with very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. A 30 percent evaluation is warranted with characteristic prostrating attacks occurring on an average once a month, over the preceding several months. A 10 percent evaluation is warranted with characteristic prostrating attacks averaging once per two months, over the preceding several months. A noncompensable rating is warranted with less frequent attacks. 38 C.F.R. § 4.124a. The Rating Schedule does not define "prostrating," nor has the Court. See Fenderson v. West, 12 Vet. App. 119 (1999) (quoting DC 8100 verbatim, but not specifically addressing the matter of what is a prostrating attack). By way of reference, "prostration" is defined as "extreme exhaustion or powerlessness." See Dorland's Illustrated Medical Dictionary 1531 (32nd ed. 2012). Similarly, "prostrate" is defined as "physically or emotionally exhausted; incapacitated." See Webster's II New College Dictionary 889 (2001). Further, "severe economic inadaptability" is also not defined in VA law. See Pierce v. Principi, 18 Vet. App. 440, 446 (2004). In addition, the Court has held that nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Id. In this regard, it was explained by the Court that if "economic inadaptability" were read to import unemployability, the appellant, should he or she meet the economic-inadaptability criterion, would then be eligible for a TDIU rather than just a 50 percent rating. Id., citing 38 C.F.R. § 4.16. The Court discussed the notion that consideration must also be given as to whether the disability was capable of producing severe economic inadaptability, regardless of whether the condition was actually causing such inadaptability. See Pierce, 18 Vet. App. at 446. In this regard, VA conceded that the words "productive of" could be read to mean either "producing" or "capable of producing." Id. at 446-447. On review, the Board finds that the criteria for a 50 percent rating for headaches are met for the entire period on appeal based on evidence of very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. In support of this finding, the Board notes that the Veteran has consistently reported experiencing frequent headaches. The January 2016 VA headaches examination report indicated that the Veteran began to develop problems with migraine headaches around the time of her TBI. The headaches occurred more frequently than once per month, and the VA examiner opined that the Veteran had very frequent prostrating and prolonged attacks of migraine headache pain that affected her ability to work. The Board notes that the January 2016 VA headaches examination is the only examination that specifically considered and explained the nature and severity of the Veteran's migraine headaches. During the July 2021 Board hearing, the Veteran testified that she has migraines once or twice a month, lasting one to two minutes. She stated that the migraines typically were alleviated by taking a painkiller within a minute or two. The migraines were overwhelming at first, because of light sensitivity. She would have to lay down and could not do anything due to the migraines. The Veteran stated that she had to leave work and go home a couple of times if she did not have the painkillers available. Resolving all reasonable doubt in the Veteran's favor, the Board finds that her description of the nature and severity of her migraine headaches during the July 2021 Board hearing is consistent with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability, particularly when she did not have access to medical treatments. In doing so, the Board notes that DC 8100 does not contemplate the effects of medication; therefore, a higher rating cannot be denied on the basis of relief provided by medication. See Jones v. Shinseki, 26, Vet. App. 56, 63 (2012). For these reasons, the Board finds that an initial rating of 50 percent is warranted for the Veteran's migraine headaches for the entire period on appeal, beginning December 20, 2010. As the Veteran is receiving the maximum schedular rating for migraine headaches, a rating higher than 50 percent for migraine headaches is not for consideration. Finally, the Board notes that neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Thomas, 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.