Citation Nr: 21025220 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 15-39 699 DATE: April 27, 2021 ORDER From June 7, 2012 to the present, a higher initial 50 percent rating, but no greater, for migraine headaches is granted. FINDING OF FACT From June 7, 2012 to the present, the Veteran’s service-connected migraine headaches are manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability, absent the ameliorative effects of the medications she takes. CONCLUSION OF LAW From June 7, 2012 to the present, the criteria have been met for the maximum 50 percent rating for migraine headaches. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.6, 4.10, 4.124a, Diagnostic Code 8100 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from January 1998 to January 2005 in the U.S. Army. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions dated in March 2014, August 2020, and February 2021, issued by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In the recent February 2021 rating decision on appeal, the AOJ granted the maximum schedular rating available for the Veteran’s migraine headaches of 50 percent - effective on and after January 28, 2021. The separate 30 percent rating for migraine headaches prior to January 28, 2021 remains on appeal. Thus, the increased rating matter on appeal has been staged by the AOJ for different periods of time. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). On this point, when filing any claim, a claimant is presumed to be seeking the maximum benefit allowed by law. See Stowers v. Shinseki, 26 Vet. App. 550, 555 (2014); AB v. Brown, 6 Vet. App. 35, 38 (1993). In fact, it is well established that a claimant who disagrees with an initial evaluation or files a claim for an increased evaluation is presumed to be seeking the highest evaluation available, unless he expressly indicates otherwise. See Breniser v. Shinseki, 25 Vet. App. 64, 79 (2011). For the time period on and after January 28, 2021, the 50 percent rating granted for the Veteran’s migraine headaches disability is the maximum schedular rating available under Diagnostic Code 8100 (migraine headaches). See 38 C.F.R. § 4.124a. That is, there is no higher schedular rating available for this disability other than 50 percent. In fact, the highest rating requested by the Veteran by way of her description of her particular symptoms for her migraine headaches was a 50 percent rating. See e.g., March 2014 NOD (VA Form 21-0958); November 2015 addendum to VA Form 9; October 2019 Veteran statement. In this respect, the Veteran has not otherwise argued that her migraine headaches were more severe, frequent, disabling, longer lasting, or caused greater economic inadaptability than what is contemplated by the 50 percent rating criteria, either on an extraschedular basis or through alternative means. Holmes v. Wilkie, 33 Vet. App. 67, 75-76 (2020). See also 38 C.F.R. §§ 3.310(a), 3.321, 4.16. The Veteran did not explain how the totality of her migraine symptoms exceeds the maximum 50 percent rating assigned under Diagnostic Code 8100. Therefore, on and after January 28, 2021, the benefits sought on appeal for the Veteran’s migraine headaches disability have already been granted in full and need not be addressed any further. In August 2018, December 2019, and November 2020, the Board remanded the appeal for further development. This case has since been returned to the Board for appellate review, after the AOJ substantially complied with the Board’s most recent remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). VA’s Duty to Notify and Assist VA’s duty to notify under the Veterans Claims Assistance Act of 2000 (VCAA) was satisfied by VA letters sent to Veteran, dated in August 2012, July 2014, July 2019, December 2019, and November 2020. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159 (2020). These letters advised the Veteran of the information and evidence necessary to substantiate her increased rating claim. In any event, in the decision below, from June 7, 2012 to the present, the Board has granted the maximum 50 percent rating available for her migraine headaches disability, throughout the entire appeal period back to the date of her original claim for service connection. Therefore, the benefits sought on appeal have been granted in full for the increased rating issue for migraine headaches. Accordingly, regardless of whether the notice and assistance requirements have been met with regard to the increased rating issue, no harm or prejudice to the Veteran has resulted. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. In any event, with regard to increased rating issue on appeal for migraine headaches, subsequent to the most recent ameliorative November 2020 Board remand, the Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that the Board has an obligation to read filings in a liberal manner, but that obligation does not require the Board to “search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Rating (IR) Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran’s lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev’d on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). However, the Board can discount lay evidence in its role as factfinder if it weighs the evidence, finds the clinical evidence more probative, and provides an explanation with supporting reasons or bases. English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Staged ratings are appropriate when the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The relevant time period for consideration in a claim for an initial disability rating is the period beginning on the date that the claim for service connection was filed. Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007). That is to say, the Board must consider whether there have been times since the effective date of her award when her migraine headaches have been more severe than at others for the time period from June 7, 2012 (the day her initial rating claim was filed) to the present. Id. However, the Board is cognizant that 38 C.F.R. §§ 4.1 and 4.2 and 4.41 require VA adjudicators to view each disability “in relation to its history” to “accurately reflect the elements of disability present,” respectively. See Jones v. Shinseki, 26 Vet. App. 56, 62 (2012); see also Moore v. Shinseki, 555 F.3d 1369, 1373 (Fed. Cir. 2009) (discussing 38 C.F.R. §§ 4.1 and 4.2 and stating that, although the veteran was “only entitled to disability compensation for the period after … the date he filed his original claim for benefits,” VA regulations still require the disability to be “evaluated in light of its whole recorded history”). Therefore, the Board has also considered and reviewed the Veteran’s entire history for her migraine headaches, when assigning a disability evaluation in the present case. 38 C.F.R. § 4.1. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. The Veteran’s migraine headaches disability is rated under Diagnostic Code 8100 (migraine headaches). 38 C.F.R. § 4.124a (2020). The Veteran’s migraine headaches disability has been staged by the AOJ for separate periods of time. From June 7, 2012 to January 28, 2021, the Veteran’s migraine headaches are rated as 30 percent disabling under Diagnostic Code 8100. (This is the time period on appeal in the present Board decision). From January 28, 2021 to the present, the Veteran’s migraine headaches are rated as 50 percent disabling (the maximum schedular rating available) under Diagnostic Code 8100. (As explained above, the 50 percent rating already assigned on and after January 28, 2021 is not on appeal here). From June 7, 2012 to January 28, 2021, in denying an initial rating above 30 percent for migraine headaches, the AOJ found that the Veteran’s migraine headaches only exhibited characteristic prostrating attacks occurring on an average once a month over the last several months during that timeframe. A higher evaluation of 50 percent was denied because the migraine headaches disability was not shown to cause very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability during this timeframe. See Diagnostic Code 8100, 38 C.F.R. § 4.124a (2020). The Veteran filed her informal service connection claim for her migraine headaches on June 7, 2012. The Veteran believes that her migraine headaches are worse than the 30 percent rating assigned prior to January 28, 2021. She experiences migraine headaches “at least” once per month (often more than once per month). Her migraine headaches have occurred on a continuous basis since 2012. Her migraine headaches can last “for hours or days.” The pain starts in the eyes and moves to her brain – the pain is throbbing and pounding in nature. She is forced to lay down in her bed. She must keep her whole body still during the migraine headache attacks. Her migraine headaches are “severely” prostrating. They interfere with her employment productivity at her desk job. At times she has had to call in sick or leave early from work due to the severity of her migraines. During her migraine headache attacks, at times during the appeal she has described experiencing other symptoms such as an aura, nausea, visual disturbances (e.g., blind spots), sensory changes, sensitivity to light, and sensitivity to any body movement. She has been given various prescription medications (Imitrex / sumatriptan) and non-prescription medications (Tylenol and Naproxen) to treat and control her migraine headaches. But throughout the appeal she has emphasized that the ameliorative impact of her headache medications in treating her symptoms should not be considered when rating this disability under VA law. See e.g., March 2014 NOD (VA Form 21-0958); October 2015 VA Form 9; November 2015 addendum to VA Form 9; October 2019 Veteran statement; and October 2019 Email from Congressional Office. Migraine headaches are rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8100, for migraines. Under Diagnostic Code 8100, a noncompensable rating is warranted for migraines with less frequent attacks. A 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 50 percent rating is the highest schedular rating under Diagnostic Code 8100. See 38 C.F.R. § 4.124a (2020). The rating criteria for Diagnostic Code 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). This renders 38 C.F.R. §§ 4.7 and 4.21 inapplicable. Johnson, 30 Vet. App. at 252. The Federal Circuit Court has held that if disability rating criteria are written in the conjunctive, as they are here, “a Veteran must demonstrate all of the required elements in order to be entitled to that higher evaluation” and 38 C.F.R. § 4.7 cannot be used to circumvent the need to demonstrate all required criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). The phrase “characteristic prostrating attacks” is used in the criteria corresponding to 10 percent and 30 percent ratings under Diagnostic Code 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. Pursuant to Dorland’s Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as “extreme exhaustion or powerlessness.” Thus, the phrase “characteristic prostrating attacks” is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness. The rating criteria for the maximum 50 percent rating contains several undefined phrases. The descriptive phrase “very frequent” connotes a frequency at least greater than once a month. Johnson, 30 Vet. App. at 253. The phrase “completely prostrating” in the 50 percent rating criteria generally means that the migraines attack must render the veteran entirely powerless. Id. The completely prostrating attacks in the 50 percent rating criteria must also be “prolonged,” which is defined as “to lengthen in time: extend duration: draw out: continue, protract.” Id. (internal citation omitted). The Court in Johnson suggested that headaches “lasting for hours” are the equivalent of the term “prolonged.” Id. at 248. The term “severe” in the 50 percent rating criteria generally means “of a great degree” or “serious.” See Merriam-Webster’s Collegiate Dictionary, 1140 (11th ed. 2003). However, the Board is cognizant of the Court’s holding that what is classified as “severe” can be dependent on the diagnostic code used. See Breniser v. Shinseki, 25 Vet. App. 64, 76-77 (2011). Lastly, the 50 percent rating criteria requires that the very frequent completely prostrating and prolonged attacks be “productive of severe economic inadaptability.” Productive can be read as having either the meaning of “producing” or “capable of producing,” and, with regard to severe economic inadaptability, nothing in Diagnostic Code 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). In rating headaches or migraines under Diagnostic Code 8100, the Board may not consider the ameliorative effects of medication. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). With regard to lay evidence, the Court has held that lay evidence may be probative of the frequency, prolongation, and severity of headaches. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). Frequency of migraine headache attacks or episodes is a factual determination. The VA must analyze all medical, lay, and other evidence in the record bearing on that question. And the absence of medical treatment is not necessarily probative on the question of headache frequency as a claimant may not seek treatment for headaches during every episode. See e.g., Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the mere absence of medical records does not contradict a Veteran’s statements about his symptom history). Initially, the Board highlights that the Court recently held that Diagnostic Code 8100 for migraine headaches contemplates “all symptoms” experienced due to migraine headache attacks, such as various non-headache symptoms – dizziness, nausea, vertigo, mood swings, sleep impairment, anxiety, isolation, and depression. In short, the rating criteria for migraines (Diagnostic Code 8100) contemplate all migraine symptoms. Holmes v. Wilkie, 33 Vet. App. 67, 73-75 (2020). VA must then rate these symptoms based on the frequency, duration, severity, and economic impact of the attacks under Diagnostic Code 8100. Id. at 72-73. However, the Court in Holmes emphasized that nothing in its analysis of Diagnostic Code 8100 forecloses the possibility that a veteran’s migraines could require additional compensation through mechanisms such as secondary service connection, a TDIU, or even an extraschedular rating under 38 C.F.R. § 3.321(b), if there was an exceptional case with symptoms more severe, frequent, or long-lasting than what is contemplated by the rating criteria. Id. at 73. See also 38 C.F.R. §§ 3.310(a), 3.321, 4.16. Upon review, from June 7, 2012 to the present, the evidence of record supports a higher initial 50 percent rating for service-connected migraine headaches under Diagnostic Code 8100. The claim is thus granted. This is the maximum schedular rating available for headaches under the applicable diagnostic code. Specifically, when adjusting for the fact that for the entire time period in question, the Veteran took various medications on a daily basis to control her migraine headache attacks, the medical and lay evidence of record establishes migraine headaches with “very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability,” thereby meeting the criteria for a 50 percent rating. See 38 C.F.R. § 4.124a. Her headache disability worsened beginning in 2012. Moreover, in making this favorable determination, under Diagnostic Code 8100, the Board has considered the functional impact of “all symptoms” experienced due to migraine headache attacks, such as various non-headache symptoms the Veteran has occasionally reported – an associated aura, nausea, visual disturbances such as blind spots, sensory changes, sensitivity to light, and sensitivity to any body movement. See Holmes, 33 Vet. App. at 73-75 (2020). That is, even with medication use, the Veteran’s migraine headache attacks are very frequent (often twice a month or more), completely prostrating, prolonged, and productive of severe economic inadaptability. Therefore, even with medication use, the Veteran still meets some, if not all of the criteria listed for the 50 percent rating under Diagnostic Code 8100. Without the use of medication, she clearly would meet all of the criteria for a 50 percent rating. When her medication was effective in controlling her headaches, it can be argued that her headache attacks were not completely prostrating and were not productive of severe economic inadaptability. However, a higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). The rating criteria for headaches listed under Diagnostic Code 8100 fail to consider the ameliorative effects of medication on the Veteran’s headaches. Therefore, the Board is obligated to contemplate the severity of her migraine headaches absent the use of her various medications (Tylenol, Naproxen, sumatriptan) to control the condition. In making this determination that the Veteran is entitled to the maximum 50 percent rating for migraine headaches under Diagnostic Code 8100, the Board has considered the following evidence of record: In a March 2012 VA primary care note, the Veteran reported “daily” headaches. She was taking Excedrin to relieve them. In the past two weeks, she reported two migraines with an aura. With one headache, she experienced a blind spot that turned into “TV snow.” There was an aching pain all over her head. Only the use of Excedrin allowed her to function. The VA clinician prescribed her sumatriptan for the first time. This corresponds to the criteria of “very frequent prostrating” migraine headaches, “productive of severe economic inadaptability” (absent the use of medications), supportive of a maximum 50 percent rating under Diagnostic Code 8100. See 38 C.F.R. § 4.124a. At a June 2012 VA H&P note, the Veteran reported that she awoke that morning and started to take a shower, but then noticed her vision alternating between total blackness and various colors before she found herself on the floor of the shower stall a few minutes later. Of note, her seeing blackness and colors is exactly what her auras are like before she has a migraine. She got out of the shower and walked to her bed where she again saw colors and passed out. Again, she found herself on the floor but then improved and went about her daily routine. Later that day at 4pm, she again experienced a severe left sided headache, similar to her migraines but more intense. Given this and her episodes of syncope with head trauma earlier in the day, she presented to VA clinicians for further evaluation/management. She was given Toradol, Zofran and IVF in the VA clinic, which helped resolve her headache. She was admitted for further evaluation and management of her “severe” migraines. This corresponds to the criteria for a maximum 50 percent rating under Diagnostic Code 8100, in that her headaches were prolonged (lasting for hours / all day) and completely prostrating (she was on the floor and powerless for a time). See 38 C.F.R. § 4.124a. A September 2012 VA headache examiner documented left-sided headache pain of the severity of 8-10 out of 10. During her migraine headache attacks, the Veteran reported that she had to lay down for five to six hours. However, the headache pain could last up to three or four days at a time. When her headaches occurred at work, she took two pain pills in order to complete her job. The Board emphasizes that a higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones, 26 Vet. App. at 63. VA treatment records dated from 2013 to 2020 confirm multiple refill requests for sumatriptan to help treat and control her migraine headaches. A January 2013 VA women’s health services note documented two headaches per month. She reported that she controlled the duration and frequency of her headaches with sumatriptan. When she experienced headaches, the Veteran detailed that she had to take repeated doses. The assessment was migraine headaches, with a plan to increased sumatriptan from 25mg to 50mg. This corresponds to the criteria of “very frequent” migraine headaches, somewhat supportive of a maximum 50 percent rating under Diagnostic Code 8100. See 38 C.F.R. § 4.124a. According to a March 2013 VA emergency department note and addendum note, the Veteran reported often experiencing a "blind spot" and “snow” in her vision preceding the onset of her migraine headaches. That day, the onset of her migraine headaches occurred around 3pm while at work. She was "unable to take anything for it". Her headache started as a frontal headache without prodrome and gradual worsened to eventually involving the right eye. By 5pm that day, the headache was no longer a simple headache and became a migraine. She took Imitrex (sumatriptan) at 5:15pm that day, with gradual improvement occurring. She reported photophobia and eye pain and nausea accompanying her migraine headaches. This corresponds to the criteria for a maximum 50 percent rating under Diagnostic Code 8100, in that her headaches were prolonged (lasting for hours) and completely prostrating (she had to be taken to the VA emergency room), “productive of severe economic inadaptability” (she had to leave work). See 38 C.F.R. § 4.124a. An April 2013 VA rheumatology note mentioned “worsening migraines on a weekly basis,” that only improve with sumatriptan. This corresponds to the criteria of “very frequent” migraine headaches, somewhat supportive of a maximum 50 percent rating under Diagnostic Code 8100. See 38 C.F.R. § 4.124a. At a May 2013 VA neurology consult, the Veteran reported migraine headaches that started as visual disturbances. The whole process took about 30 minutes. The headache felt like “my brain hurts.” She stated sometimes it felt like someone is standing on her head, or a brick is pushing on the left side of her head. It sometimes felt like a balloon getting bigger or a “stick going through her brain.” She stated that any movement at all is terrible. She could feel sensitivity to light at times. When a headache occurred, she would lie down, but it does not have to be a dark room. She used to take Excedrin for her headaches, which would make it possible to lie down. She added that sometimes the headache pain was so severe that she could not move. Only 25 mg for her migraines took away most of the pain, but not all of it. She experienced migraines at the rate of 2-4 per month. They could last as long as three days, but usually went away after one day. She experienced 10 headache days per month, with about 3-4 days per month being severe. Her headaches usually occurred in the evenings. The assessment was migraine headaches that were becoming more frequent. Her headaches were preceded by a central scotoma which lasted about 30 minutes before her headaches began. She was taking sumatriptan at the time of the consultation for abortive therapy which worked after a couple of doses. She considered Topamax or Elavil for migraine prevention. This corresponds to the criteria for a maximum 50 percent rating under Diagnostic Code 8100, in that her headaches were prolonged (lasting for one to three days) and completely prostrating (she has to lie down and not move at all), “productive of severe economic inadaptability” (she cannot work when she lies down and cannot move). See 38 C.F.R. § 4.124a. A September 2013 VA neurology note recorded at least four headaches per month for the Veteran. She stopped taking amitriptyline (Elavil) for headaches in mid-August 2013 because of fatigue. She last had a severe headache on September 11th, 2013. She used Imitrex three times in the past month to control the pain. She also took Naproxen daily. She called in mid-August 2013 to report a spell in which she had weakness as she stood up out of the bed in the morning. This resulted in her collapsing to the floor, but she could not recall any numbness. She was able to get up after a few minutes and lie down in bed again. Within 15-20 minutes, she was fine. This corresponds to the criteria of “very frequent” migraine headaches, somewhat supportive of a maximum 50 percent rating under Diagnostic Code 8100. See 38 C.F.R. § 4.124a. In an October 2013 VA neurology note, the Veteran described 13 headaches since she was last seen. The headaches were described as pressure and stabbing in the four corners of her head. Motion could aggravate the headaches. She had five of her regular migraines with aura headaches that always begin with visual disturbance as a blind spot that evolves into colored lights. This broke up in the middle of her vision and expanded outwardly until it went away over a period of 20-45 minutes followed by the headache itself. Her migraine headaches were different than the milder headaches in that they “feel like her brain hurts.” They were pulsating, worse with movement, but without photophobia, phonophobia, or nausea. These headaches occurred at least weekly before she was first seen in the VA emergency room in the spring of 2013. She cut down on naproxen since last seen. She took the naproxen for just four days and also used sumatriptan for four days in the past month with several of these days overlapping. The assessment and plan was migraine with aura, currently with five episodes per month. She was interested in the ethosuximide versus placebo migraine study, and she was enrolled that day. This corresponds to the criteria for a maximum 50 percent rating under Diagnostic Code 8100, in that her headaches were prolonged (lasting for hours) and completely prostrating (she has to lie down and not move at all), “productive of severe economic inadaptability” (she cannot work when she lies down and cannot move). See 38 C.F.R. § 4.124a. A November 2013 VA initial evaluation note assessed “frequent” migraine headaches for the Veteran. A January 2014 VA headache examination documented that only medications control her migraine frequency. At that time, she was in a double-blind study in which she took a preventative drug since December 2013. Her sumatriptan was helpful when her migraine headaches did occur. Her medications decreased the frequency and severity of the headaches. She had two migraine headache attacks in the past month. This VA examination demonstrates that absent the use of various medications, her headaches were much worse to the point of being “completely prostrating,” meaning that they would render the Veteran entirely powerless. Johnson, 30 Vet. App. at 253. A February 2014 VA research note assessed two migraine headaches in the past month or so. A June 2014 VA women’s health consult noted “severe” headaches every three weeks. These headaches only improved when she takes sumatriptan. In her October 2015 VA Form 9, the Veteran competently and credibly advised that she had stopped seeking clinical treatment at the VA for her headaches because VA doctors told her there is nothing they can do for her migraines aside from the prescription and non-prescription medications she took to control their severity. Indeed, lay testimony regarding what a medical professional tells a lay person is specifically listed as one of the examples given as competent lay testimony. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In the November 2015 addendum to the VA Form 9, the Veteran further indicated her migraines could last for hours or days. She did not move her body during her migraine headache attacks. In the month of October 2015, she said she experienced two severe migraine attacks. The Board emphasizes that lay evidence may be probative as to the frequency, prolongation, and severity of headaches. Pierce, 18 Vet. App. at 445-46. VA treatment records from 2015 to 2019 included a migraine journal in which the Veteran emailed VA clinicians periodically, advising them of the severity and frequency of her migraine headache attacks. She also requested prescription refills to treat her migraines. For example, she reported a November 2015 migraine headache attack that lasted the entire day. She lay down for five hours. She was sick for the rest of the day and could not work. She reported two migraine attacks in January 2016 during which she had to leave work early and lay in bed due to “horrible” pain. A migraine attack in March 2016 lasted for two days. She experienced two migraine attacks in April 2016, with one lasting for two days. She experienced two migraine attacks in July 2016. She had to leave work due to one of them. She experienced two migraine attacks in September 2016, each lasting for two days. She reported multiple migraine headache attacks in October 2016, November 2016, December 2016, January 2017, February 2017, March 2017, April 2017, May 2017, June 2017, July 2017, and August 2017. In 2018 she advised that her migraine headaches occur every month. She requested a renewal of her prescriptions for sumatriptan and naproxen to help control her migraine headaches. In 2019 she stated she was experiencing prostrating attacks of migraine headaches “at least” one or more a month, which interfere with employment productivity. The Board again emphasizes that lay evidence may be probative on the frequency, prolongation, and severity of headaches. Pierce, 18 Vet. App. at 445-46. At an April 2019 VA primary care H&P note, the Veteran reported “chronic” migraine headaches, only relieved by Imitrex within two hours of taking it. A May 2019 VA headache examination documented migraine headaches “at least” once a month. Prior to the onset of migraines, she experienced a blind spot in one eye that grew bigger and bigger. She felt like she was going through a tunnel all from her eye. Then the headache began within minutes to an hour. The duration of her headaches varied “from hours to days.” The headache pain was “constant” pain that felt like a pointed brick stuck in the left side of her head. Sometimes it felt like something was in her brain and pushing outwards. Her migraine headaches were accompanied by vision changes and sensory changes, with any movement of her body making them worse. At her job as a resource analysis, she was unable to drive or use the keyboard when she experienced a migraine headache. Instead, she typically would lie down and go to sleep when they occurred. She took several medications to control her migraine headaches - Tylenol 500mg and Sumatriptan 50mg once and then two hours later if needed. This corresponds to the criteria for a maximum 50 percent rating under Diagnostic Code 8100, in that her headaches were prolonged (“from hours to days”) and completely prostrating (she lays down and does not move her body), “productive of severe economic inadaptability” (she cannot work when her migraines occur as she cannot type and must lay down and go to sleep). See 38 C.F.R. § 4.124a. In an October 2019 Email from a Congressional Office, the Veteran argued that her medication treatment by way of Imitrex was being used by VA to deny a higher evaluation. She advised that sleep is the only effective treatment for her migraines, which are “severely prostrating.” A January 2020 VA headache examination with a medical opinion on employability indicated the Veteran experienced up to five migraines per month. Her migraines started with a blind spot in her eye, then developed into pain on the right side of the head. Her migraines could last up to two to three days at a time. During her migraine episodes, the Veteran reported vision changes, feeling fatigued, powerless, and ensconced in malaise. Her functionality was reduced during migraine attacks. It felt like her brain hurt during migraine attacks. Her migraines were progressively worse since their onset. At her job as a resource analyst, she reportedly lost 1-2 weeks work time during the last 12 months. Her migraines rendered her “powerless and exhausted.” She was unable to drive or type during a migraine attack. Her functionality was reduced during migraine attacks. This corresponds to the criteria for a maximum 50 percent rating under Diagnostic Code 8100, in that her headaches were prolonged (lasting for two to three days) and completely prostrating (she is powerless, exhausted, and full of malaise), “productive of severe economic inadaptability” (she cannot work when her migraines occur as she cannot type and is powerless). See 38 C.F.R. § 4.124a. A June 2020 VA primary care note confirmed three migraine headaches during the previous month. She reported that her number of headaches had increased recently. The VA clinician renewed her prescription for sumatriptan 50mg. A January 2021 VA addendum opinion for headaches found that her migraine headaches lasted up to four days, typically less than 1 day, and that they worsened since their onset. She took sumatriptan to control her headaches. During her migraine headache attacks, she also experienced changes in vision and sensitivity to movement. The VA examiner concluded that the Veteran had “very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability.” This impacted her ability to work due to severe headaches with associated vision loss, decreased focus, decreased concentration, and a reduction in overall productivity at work. The Veteran reported missing work approximately one time per month secondary to the severe headaches. The VA examiner also concluded the Veteran experienced prostrating attacks of migraine/non-migraine headache pain “more frequently than once per month.” This corresponds to the criteria for a maximum 50 percent rating under Diagnostic Code 8100, in that her headaches were prolonged (lasting up to four days) and completely prostrating, “productive of severe economic inadaptability” (she misses work when her migraines occur as she cannot concentrate or focus, resulting in an overall reduction in productivity on the job). See 38 C.F.R. § 4.124a. In summary, from June 7, 2012 to the present, the Board concludes that if the Veteran did not constantly take prescription and non-prescription medications, her migraine headaches would nearly always be classified as very frequently “completely prostrating” and contributing to prolonged attacks productive of “severe” economic inadaptability. This corresponds to the criteria for a maximum 50 percent rating under Diagnostic Code 8100. See 38 C.F.R. § 4.124a. Her headaches occur on a “very frequent” basis, connoting a frequency at least greater than once a month. Johnson, 30 Vet. App. at 253. Absent her medication use, the headaches are “completely prostrating” meaning they would render the Veteran entirely powerless. Id. Her headaches are almost always “prolonged” in that they can last “for hours or days” according to the Veteran. Johnson, 30 Vet. App. at 248. And absent her various medications, her headaches are almost always “productive” of severe economic inadaptability, meaning “producing” or “capable of producing,” severe economic inadaptability. Pierce, 18 Vet. App. at 445-46. In this regard, although the Veteran is currently employed at a desk job, her migraine headache attacks at times caused her to have to call in sick or leave work early due to the severity of her migraines. However, nothing in Diagnostic Code 8100 requires the Veteran to be completely unable to work in order to qualify for the maximum 50 percent rating. Id. Finally, in awarding the maximum 50 percent rating, the Board has considered the effect of other symptoms occasionally associated with her headaches – an aura, nausea, visual disturbances (e.g., blind spots), sensory changes, sensitivity to light, and sensitivity to any body movement. Holmes, 33 Vet. App. at 73-75. Accordingly, from June 7, 2012 to the present, a maximum 50 percent rating is warranted for the Veteran’s service-connected migraine headaches. 38 C.F.R. § 4.3. No higher schedular rating is available for this disability. The claim is granted. Finally, for the migraine headaches issue, from June 7, 2012 to the present, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (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). Moreover, the Veteran has not explained how the totality of her migraine symptoms would exceed the 50 percent schedular rating criteria contained in Diagnostic Code 8100. See Holmes, 33 Vet. App. at 75. C. M. Collins Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P.S. Rubin, 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.