Citation Nr: 21023195 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 15-10 596A DATE: April 20, 2021 ORDER Entitlement to an initial rating in excess of 50 percent for service-connected migraine headaches associated with traumatic brain injury (migraines) is denied. Entitlement to an initial rating in excess of 10 percent for service-connected traumatic brain injury (TBI) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU), based on service-connected migraines alone, is granted. Entitlement to special monthly compensation (SMC) based on housebound status is granted. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran has been in receipt of the maximum rating for migraine headaches. 2. For the entire period on appeal, the Veteran’s TBI was manifested by symptomatology no worse than level one impairment for any of the relevant facets according to the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table. 3. The evidence is at least in equipoise as to whether the Veteran’s service-connected migraines render her unable to secure or follow substantially gainful employment. 4. The Veteran is in receipt a total disability rating for his service-connected migraines, and his other service-connected disabilities are rated at least 60 percent throughout the period on appeal. CONCLUSIONS OF LAW 1. For the entire period on appeal, the Veteran has been in receipt of the maximum rating for migraine headaches. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.14, 4.124a, Diagnostic Code (DC) 8100. 2. The criteria for an initial disability rating in excess of 10 percent for service-connected TBI have not been met at any point during the period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.21, 4.124a, DC 8045. 3. The criteria for entitlement to a TDIU, based on service-connected migraines alone, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 4. The criteria for SMC based on housebound status have been met. 38 U.S.C. §§ 1114(s); 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1966 to November 1968, and from January 1969 to May 1973. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2016 rating decision issued by a Department of Veterans Affairs (VA) regional office. In an August 2018 decision, the Board granted an initial rating of 10 percent for the Veteran’s service-connected TBI, but denied a rating in excess of 10 percent, and denied the Veteran’s claim of entitlement to a rating in excess of 50 percent for his service-connected migraines. The Veteran appealed the Board’s denials to the United States Court of Appeals for Veterans Claims (Court). In an October 2019 decision, the Court granted a Joint Motion for Partial Remand (JMPR) and remanded the claims to the Board for further proceedings. The Board subsequently remanded the claims for further development in August 2020. As an initial matter, the Board notes that, when evidence of unemployability is submitted during the course of an appeal of an assigned disability rating, a claim for entitlement to a TDIU will be considered to have been raised by the record as “part and parcel” of the underlying claim. Rice v. Shinseki, 22 Vet. App. 447, 453-454 (2009). Here, the record indicates that, in an April 2020 rating decision, the Veteran was awarded a TDIU for the entire period on appeal due to her service-connected migraines, TBI, and degenerative arthritis of the lumbar spine. However, the Veteran, through her representative, has asserted that a TDIU is warranted based solely on her service-connected migraines. See March 2021 Correspondence. As such, the issue of entitlement to a TDIU based solely on the Veteran’s service-connected migraines is before the Board on appeal and is properly included in the list of issues before the Board. See Rice v. Shinseki, supra. Likewise, the Veteran, through her representative, has asserted that SMC due to housebound status is warranted. See March 2021 Correspondence. As such, the issue of entitlement to SMC due to housebound status is before the Board on appeal and is properly included in the list of issues before the Board. See Akles v. Derwinski, 1 Vet. App. 118 (1991). INITIAL RATING Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where a claimant timely appeals the rating initially assigned for the service-connected disability, VA must consider whether the claimant is entitled to “staged” ratings to compensate them for times since filing the claim when their disability may have been more severe than at other times during the course of the appeal. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § § 4.7. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. §§ 3.102, 4.3. Factual and Procedural Background. In a May 2016 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for TBI and migraines, effective June 26, 2013, and assigned a noncompensable and 30 percent rating, respectively. Thereafter, in May 2016, the Veteran submitted a Notice of Disagreement (NOD) as to the initial ratings assigned. This appeal was ultimately perfected. In a June 2017 rating decision, the AOJ granted a rating of 50 percent for the Veteran’s service-connected migraines, effective June 26, 2013. In an August 2017 rating decision, the AOJ granted a rating of 10 percent for the Veteran’s service-connected TBI, effective August 7, 2017. In a December 2018 decision, the Board granted a rating of 10 percent for the Veteran’s service-connected TBI, effective June 26, 2013. The Board also found that a rating in excess of 10 percent for the Veteran’s service-connected TBI was not warranted at any time during the period on appeal, and that a rating in excess of 50 percent for the Veteran’s service-connected migraines was not warranted. In an October 2019 decision, the Court granted a JMPR and remanded the claims to the Board for further proceedings. The JMPR found that the Board erred when it adjudicated the Veteran’s claims based on evidence that had not been considered by the AOJ without obtaining a waiver or explaining how the Veteran was not prejudiced by such. The JMPR also noted that the Veteran had asserted that symptoms of vertigo and nausea were possibly residuals of her TBI and instructed the Board to address the argument on remand. In August 2020, the Board remanded the matters for further development. The Veteran’s VA treatment records indicate that during the period on appeal, the Veteran reported experiencing migraine headaches three times weekly, with associated nausea, lightheadedness, and photosensitivity. The records also indicate that she reported experiencing memory problems, such as forgetting what she is doing or why she entered in a room as early as July 2014; however, the Veteran denied getting lost in familiar places or placing common objects in incorrect places, and she reporting she was able to drive. See Minneapolis VAMC records, received November 2017, February 2018, May 2018, August 2018, February 2019, August 2020, and January 2021 in CAPRI. In April 2016, the Veteran underwent VA examinations regarding her TBI and migraines, in which the Veteran reported experiencing issues with memory and concentration over the last two years. In this examination, the examiner noted normal judgment, routinely appropriate social interaction, normal motor activity, and normal visual spatial orientation. The examiner also noted that the Veteran was always fully oriented, was able to communicate and comprehend spoken and written language, and did not have subjective symptoms or neurobehavior effects. The examiner further noted that the Veteran experienced migraines associated with her TBI, which presented with nausea, vomiting, and sensitivity to light and sound, and manifested with prostrating attacks approximately once per month. The examiner also noted that the Veteran’s reported memory and concentration issues were less likely than not related to her TBI as they began two years prior, and if they were related to her TBI they would be expected to begin and persist since the time of the TBI. Lastly, the examiner stated that while the Veteran’s TBI did not impact her ability to work, her migraines did impact such ability. Specifically, the examiner noted that the Veteran sometimes missed work due to her headaches, and that she had lost two jobs due to such absences. See April 2016 VA Initial Evaluation of TBI Disability Benefits Questionnaire (DBQ); April 2016 VA Headaches DBQ. In March 2017, the Veteran submitted an examination report, conducted by a private physician in August 2016, regarding her headaches. In this examination, the physician noted that the Veteran experienced migraines up to three time per week that presented with vertigo, nausea, vomiting, malaise, sensitivity to light, mood changes, and mental confusion/inability to concentrate, and that her migraines manifested with prostrating attacks up to three times per week. The physician also noted that the Veteran would likely be absent from work more than three times per month due to her migraines. However, the physician declined to opine as to whether the Veteran’s migraines rendered her incapable of performing gainful employment, stating that they were unable to give an opinion. See March 2017 Private Headaches Impairment Questionnaire. In August 2017, the Veteran underwent VA examinations regarding her TBI and migraines, in which the Veteran reported experiencing difficulty following conversations, recalling recent conversations, remembering names, attention, concentration, and short-term memory since her TBI in 1966. In this examination, the examiner noted normal judgment, routinely appropriate social interaction, normal motor activity, and normal visual spatial orientation. The examiner also noted that the Veteran was always fully oriented, was able to communicate and comprehend spoken and written language, and did not have neurobehavior effects, but did have subjective symptoms of severe migraines up to two times per week. The examiner further noted that the Veteran reported mild memory loss, attention, and concentration, but without objective evidence on testing; a Montreal Cognitive Assessment noted a score of 25/30, with 26 or higher being normal. The examiner also noted that the Veteran experienced migraines up to two times per week and presented with nausea and sensitivity to light and sound but did not manifest with prostrating attacks. Lastly, the examiner stated neither the Veteran’s TBI nor her migraines impacted her ability to work. See August 2017 VA Review TBI DBQ; August 2017 VA Montreal Cognitive Assessment; August 2017 VA Headache DBQ. In February 2018, the Veteran underwent VA examinations regarding her TBI and migraines, in which the Veteran reported that her attention, concentration, and short-term memory had worsened since the August 2017 examination, in that she will forget something and then forget it all over again within minutes of trying to remember it. In this examination, the examiner noted normal judgment, routinely appropriate social interaction, normal motor activity, and normal visual spatial orientation. The examiner also noted that the Veteran was always fully oriented, was able to communicate and comprehend spoken and written language, and did not have neurobehavior effects, but did have subjective symptoms of severe migraines up to two times per week. The examiner further noted that the Veteran reported mild memory loss, attention, and concentration, but without objective evidence on testing. The examiner also noted that the Veteran experienced migraines up to two times per week, presented with nausea and sensitivity to light and sound, and manifested with prostrating attacks approximately once per month. Lastly, the examiner stated that both the Veteran’s TBI and her migraines impacted her ability to work. Specifically, the examiner noted that the Veteran’s impairment in attention, concentration, and memory all impacted her ability to work, and that she needed to lay down in a quiet, dark room with onset of migraines. Nonetheless, the examiner concluded that the Veteran was capable of performing sedentary work. See February 2018 VA Review TBI DBQ; February 2018 VA Headache DBQ. In June 2018, the Veteran submitted an examination conducted by a private physician regarding her headaches. In this examination, the physician noted that the Veteran experienced migraines up to three time per week that presented with nausea, vomiting, malaise, sensitivity to light, and inability to concentrate, and that her migraines manifested with prostrating attacks up to three times per week. The physician also noted that the Veteran would likely be absent from work more than three times per month due to her migraines. Lastly, the physician opined that, due to the frequency and severity of her migraines, the Veteran was not capable of performing gainful employment. See June 2018 Private Headaches Impairment Questionnaire. In July 2018, the Veteran submitted an examination, conducted by a private physician in May 2018, regarding her TBI. In this examination, the physician noted normal motor activity and visual spatial orientation, as well as social interaction that is routinely appropriate. The physician also noted mildly impaired judgment, occasional disorientation to one of the four aspects (person, time, place, situation) of orientation, three or more subjective symptoms that mildly interfere with work, ability to communicate and comprehend spoken and written language, and one or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. The physician noted complaints of mild memory loss, attention, or concentration, but without objective evidence on testing. Lastly, the physician opined that, due to the frequency of the Veteran’s migraines, she was not capable of performing gainful employment. See July 2018 Private TBI Impairment Questionnaire. In July 2019, the Veteran underwent a VA examination regarding her migraines, in which the examiner noted that the Veteran’s migraines presented with nausea, vomiting, and sensitivity to light and sound, and manifested with prostrating attacks less frequently than one once every two months. The examiner also stated that the Veteran’s migraines impacted her ability to work, noting that she experienced migraines at least 15 times per month, and although symptoms could be controlled with medication, she would need to lay down two to four hours after taking the medication. See July 2019 VA Headache DBQ. In January 2021, the Veteran underwent VA examinations regarding her TBI and migraines, in which the Veteran reported experiencing forgetfulness and trouble with short term memory. In this examination, the examiner noted normal judgment, routinely appropriate social interaction, normal motor activity, and mildly impaired visual spatial orientation in that the veteran reported getting lost easily and experiencing difficulty using maps or GPS. The examiner also noted that the Veteran was always fully oriented, was able to communicate and comprehend spoken and written language, and did not have neurobehavior effects, but did have subjective symptoms of severe migraines up to two times per week. The examiner further noted that the Veteran reported mild memory loss, attention, and concentration, but without objective evidence on testing. Additionally, the examiner noted that the Veteran experienced migraines up to two times per week which presented with nausea and sensitivity to light and sound, and that her migraines did not present with prostrating attacks. The examiner also noted that the Veteran’s reported occasional dizziness or lightheadedness were symptoms of her migraine headaches. Lastly, the examiner stated that the Veteran’s TBI and migraines impacted her ability to work, noting that she would need to take time off when she had a bad headache. See January 2021 Review TBI DBQ; January 2021 VA Headaches DBQ; January 2021 VA Ear Conditions DBQ. Analysis. 1. Entitlement to an initial rating in excess of 50 percent for service-connected migraines is denied. The Veteran seeks a higher rating for her service-connected migraines, which are currently rated at 50 percent for the entire period on appeal. This represents the highest schedular rating available for migraine headaches under DC 8100. See 38 C.F.R. § 4.124a, DC 8100. Importantly, as this is an appeal as to the initial rating assigned, the relevant temporal focus is from June 26, 2013, the effective date of the award of service connection, to current. Ordinarily, the VA schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Per the regulation, an extra-schedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the veteran’s level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran’s disability picture exhibits other related factors such as those provided by the regulation as governing norms. Third, if the rating schedular is inadequate to evaluate a veteran’s disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Director of the Compensation and Pension Service (Director) to determine whether the veteran’s disability picture requires the assignment of an extraschedular rating. With respect to the first Thun step, the sole focus is on the ability of the rating schedule to evaluate the veteran’s symptomatology as an extraschedular rating is not applicable to claims that may be properly evaluated with conventional schedular rating tools. In other words, the first Thun step exclusively asks whether a veteran’s symptoms are exceptional. See Long v. Wilkie, 33 Vet. App. 167 (2020); Morgan v. Wilkie, 31 Vet. App. 162 (2019); Yancy v. McDonald, 27 Vet. App. 484 (2016). Here, the evidence demonstrates that the Veteran’s migraines have presented with dizziness/lightheadedness, nausea/vomiting, malaise, inability to concentrate, and sensitivity to light and sound, and has manifested with prostrating attacks occurring, at worst, up to three times per week. With respect to the frequency of the Veteran’s prostrating attacks, DC 8100 specifically instructs that a maximum 50 percent rating be assigned for frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. With respect to the Veteran’s symptoms of dizziness/lightheadedness, nausea/vomiting, malaise, inability to concentrate, and sensitivity to light and sound, the Board notes that DC 8100 contemplates all migraine symptoms. See Holmes v. Wilkie, 2020 U.S. Vet. App. LEXIS 2131. As the Veteran’s symptomatology and effects are contemplated by the rating schedule, the first Thun step has not been met and, therefore, the second and third Thun steps become moot. As such, referral to the Director for extra-schedular consideration is not warranted. As there is no legal basis to award a schedular evaluation in excess of 50 percent, and as extra-schedular consideration is not warranted, the claim for increased rating must be denied. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an initial rating in excess of 10 percent for service-connected TBI is denied. TBI residuals are rated under 38 C.F.R. § 4.124a, DC 8045, based on three main areas of dysfunction: cognitive, emotional/behavioral, and physical. 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. Cognitive impairment is to be rated under the table titled Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified (TBI Table). See 38 C.F.R. § 4.124, DC 8045. Subjective symptoms are to be evaluated under the subjective facet of the TBI Table whether or not they are part of cognitive impairment, unless they have a distinct diagnosis that may be evaluated under a separate diagnostic code, such as Meniere’s disease or migraine headaches. See id. When there is a diagnosis of a mental disorder, such is to be rated under 38 C.F.R. § 4.130. When there is no diagnosis of a mental disorder, such dysfunction is to be rated under the TBI Table. Physical and neurological dysfunction is to be evaluated separately under the appropriate diagnostic code. See id. The TBI Table contains 10 important facets of a TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from zero to three, and a fifth 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 totalling disabling. See id. A 100 percent rating is assigned if “total” is the level of evaluation for one or more facets. If no facet is evaluated as “total,” the overall percentage rating is assigned based on the level of the highest facet as follows: 0 equals noncompensable; 1 equals 10 percent; 2 equals 40 percent; and 3 equals 70 percent. For example, a 70 percent rating is assigned if the highest level of evaluation for any facet is 3. The 10 cognitive impairment facets are: consciousness, communication, neurobehavioral effects, subjective symptoms, visual spatial orientation, motor activity, orientation, social interaction, judgment, and one facet encompassing memory, attention, concentration, and executive function. See id. There may be an overlap of manifestations of conditions evaluated under the TBI Table and manifestations of a comorbid mental or neurologic disorder or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, no more than one evaluation is to be assigned based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, a single evaluation is assigned under whichever set of diagnostic criteria allows the better assessment of overall impair functioning due to both conditions. However, if the manifestations are clearly separable, a separate evaluation is assigned for each condition. See id. Symptoms listed as example at certain evaluation levels in the TBI Table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Instrumental activities of daily living refer to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, laundry, responsibility for one’s own medications, and using a telephone. These activities are distinguished from activities of daily activities, which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. The terms mild, moderate, and severe TBI, which may appear in medical records, refer to a classification of a TBI at the time of injury rather than to the current level of functioning; this classification does not affect the rating assigned under DC 8045. See id. Here, the Veteran seeks a rating in excess of 10 percent for her service-connected TBI. Importantly, as this is an appeal as to the initial rating assigned, the relevant temporal focus is from June 26, 2013, the effective date of the award of service connection, to current. The record indicates that, throughout the period on appeal, the Veteran’s TBI residuals have consistently manifested with routinely appropriate social interaction, normal motor activity, the ability to communicate by, and comprehend, spoken and written language, normal consciousness, and no neurobehavioral effects. This corresponds to an evaluation of 0 for the social interaction, motor activity, communication, consciousness, and neurobehavioral effects facets, respectively. See June 2016 VA Initial TBI DBQ; August 2017 VA Review TBI DBQ; February 2018 Review TBI DBQ; July 2018 Private TBI Impairment Questionnaire; January 2021 VA Review TBI DBQ. Likewise, the record indicates that the Veteran has consistently reported mild loss of memory, attention, and concentration, but there is no objective evidence of such on testing. See id. This corresponds to an evaluation of 1 under the memory, attention, concentration, and executive functions facet. With respect to the judgment facet, VA examinations have consistently noted that the Veteran’s judgment is normal. However, the July 2018 private examination noted mildly impairment judgment. See id. Under the judgment facet, mild impairment corresponds to an evaluation of 1. Similarly, VA examinations have consistently found the Veteran to be always oriented to person, time, place, and situation. However, the July 2018 private examination determined that the Veteran was occasionally disoriented to one of the four aspects of orientation. See id. Under the orientation facet, occasional disorientation of one of the four aspects of orientation corresponds to an evaluation of 1. Likewise, the Veteran has consistently been found to have normal visual spatial orientation. However, the January 2021 VA examiner found the Veteran’s visual spatial orientation to be mildly impaired, noting that the Veteran reported getting lost easily and having trouble using a map or GPS. See id. Under the visual spatial orientation facet, mild impairment corresponds to an evaluation of 1. With respect to the subjective symptoms facet, VA examinations have consistently found that the Veteran has subjective symptoms that do not interfere with work, instrumental activities of daily living, or relationships. However, the July 2018 private examiner determined that the Veteran has three or more subjective symptoms that mildly interfere with work, instrumental activities of daily living, or relationships; the examiner did not elaborate or identify any symptoms. See id. Under the subjective symptoms facet, three or more subjective symptoms that result in mild interference corresponds to an evaluation of 1. The Board acknowledges that the Veteran has reported experiencing sensitivity to light and sound, dizziness/lightheadedness, nausea/vomiting, and malaise. However, such symptoms have been attributed the Veteran’s service-connected migraines, and as such are contemplated by the rating assigned thereto. See id.; April 2016 VA Headaches DBQ; March 2017 Private Headaches Impairment Questionnaire; August 2017 VA Headache DBQ; February 2018 VA Headache DBQ; June 2018 Private Headaches Impairment Questionnaire; July 2019 VA Headache DBQ; January 2021 VA Headaches DBQ; January 2021 VA Ear Conditions DBQ; see also Holmes v. Wilkie, supra. Based on the above, the Board finds that, throughout the period on appeal, the Veteran’s TBI residuals have manifested with, at worst, evaluations of 1 under the judgment, orientation, visual spatial orientation, and subjective symptoms facets. Therefore, at no point during the period on appeal has the Veteran’s TBI manifested with an evaluation higher than 1 for any of the TBI facets. As such, a rating in excess of the 10 percent already assigned is not supported by the evidence of record, and the claim is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to a TDIU, based on service-connected migraines alone, is granted. As an initial matter, the Board notes that, in an April 2020 rating decision, the Veteran was awarded a TDIU, effective June 26, 2013, based on her service-connected migraines, degenerative arthritis of the lumbar spine, and degenerative arthritis of the cervical spine. However, the Veteran, through her representative, has asserted that a TDIU is warranted based on her service-connected migraines alone. See February 2021 Correspondence. Importantly, as this matter arises from the appeal of the initial rating assigned for the Veteran’s migraines, the relevant temporal focus is from June 26, 2013, the effective date of the award of service connection for migraines, to current. See Rice v. Shinseki, 22 Vet. App. 447, 453-454 (2009); Norris v. West, 12 Vet. App. 413 (1999). A total rating for compensation purposes may be assigned where the schedular rating is less than total, when it is found that the claimant is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability rated at 60 percent or more, or as a result of multiple service-connected disabilities, provided one of the disabilities is rated at 40 percent or more and the others bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In evaluating a veteran’s employability, consideration may be given to his level of education, special training, and previous work experience, but not to their age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The fact that a Veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether a veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). Pertinent to this inquiry, the Board notes that, beginning June 26, 2013, the Veteran has been service-connected for: migraines, rated at 50 percent; status post total hysterectomy associated with endometriosis, rated at 30 percent; lumbar spine degenerative arthritis, rated at 40 percent prior to October 16, 2013, and at 20 percent thereafter; tinnitus, rated at 10 percent; cervical spine degenerative arthritis, rated at 10 percent; chronic urinary tract infections, rated at 10 percent; left lower extremity radiculopathy, rated at 10 percent; right lower extremity radiculopathy, rated at 10 percent; TBI, rated at 10 percent; bilateral hearing loss, rated as noncompensable; and endometriosis, rated as noncompensable. Throughout the appeal period, the Veteran’s combined rating has been 90 percent. Therefore, the schedular threshold for TDIU consideration has been met. See C.F.R. § 4.16(a). As noted above, the Veteran has undergone several examinations, both VA and private, regarding the severity of her service-connected migraines. With the exception of a March 2017 private examination and an August 2017 VA examination, these examinations have consistently determined that the Veteran’s migraines impact her ability to work. Specifically, the examinations have consistently found that the Veteran’s migraines required her to lay down in a dark, quiet room, that she would miss work due to her migraines, and that she had lost two jobs due to the frequency of such absences. See April 2016 VA Headaches DBQ; February 2018 VA Headache DBQ; June 2018 Private Headaches Impairment Questionnaire; January 2021 VA Headaches DBQ. Further, the July 2019 examiner concluded that the Veteran’s migraines impacted her ability to work, noting that, absent medication, she experienced at least 15 migraines per month, with each migraine lasting up to one day. The examiner also noted that, though the Veteran’s symptoms could be controlled with medication, she needed to lay down for up to four hours after taking the medication. See July 2019 VA Headache DBQ. The Board notes that the ameliorative effects of medication are not to be considered when evaluating migraines. See Jones v. Shinseki, 26 Vet. App. 56 (2012). Additionally, though the March 2017 private physician declined to opine as to whether the Veteran was capable of performing gainful employment, the physician noted that the Veteran experienced approximately three prostrating headaches per week. See March 2017 Private Headaches Impairment Questionnaire. Similarly, though the August 2017 VA examiner concluded that the Veteran’s migraines did not impact her ability to work, the examiner noted that she experienced migraines, approximately two times per week, that were worsened with bright lights, sound, and exertion, and were alleviated with medication and laying down in a dark, quiet room. See August 2017 VA Headache DBQ. In sum, the evidence indicates that the Veteran’s migraines are exacerbated by bright lights, sound, and exertion, are alleviated by laying down in a dark quiet room. The evidence also indicates that, absent medication, the Veteran’s migraines last up to one day and occur at least 15 times per month. Based on the above, the Board finds the evidence of record overall supports the finding that the Veteran’s service-connected conditions render the Veteran unable to secure or follow a substantially gainful occupation, at least to an evidentiary degree of equipoise. Accordingly, the Board resolves all reasonable doubt in the Veteran’s favor, and finds entitlement to TDIU, based on service-connected migraines alone, to be warranted, effective June 26, 2013. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). 4. Entitlement to SMC based on housebound status is granted. SMC based on housebound status is payable where the Veteran has a single service-connected disability rated as 100 percent disabling and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. As a result of the Board’s decision above, the Veteran is in receipt of a TDIU, based on her service-connected migraines alone, effective June 26, 2013. Thus, for SMC purposes, this disability satisfies the requirement of a “service-connected disability rated as total” for this period. See Blue v. Shinseki, 24 Vet. App. 242, 251 (2011); Bradley v. Peake, 22 Vet. App. 280, 293 (2008). Beginning June 26, 2013, the Veteran is also service-connected for: status post total hysterectomy associated with endometriosis, rated at 30 percent; lumbar spine degenerative arthritis, rated at 40 percent prior to October 16, 2013, and at 20 percent thereafter; tinnitus, rated at 10 percent; cervical spine degenerative arthritis, rated at 10 percent; chronic urinary tract infections, rated at 10 percent; left lower extremity radiculopathy, rated at 10 percent; right lower extremity radiculopathy, rated at 10 percent; TBI, rated at 10 percent; bilateral hearing loss, rated as noncompensable; and endometriosis, rated as noncompensable. For these disabilities, her combined rating was 80 percent prior to October 16, 2013, and 70 percent thereafter. See 38 C.F.R. § 4.25. (Continued on the next page)   In sum, the Veteran has a single service-connected disability rated at 100 percent (i.e. her migraines), and her additional service-connected disabilities are independently rated at over 60 percent as of June 26, 2013. As such, entitlement to SMC based on housebound status is warranted, effective June 26, 2013. See 38 U.S.C. § 1114(s). YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. T. Martin III, Associate 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.