Citation Nr: 21029846 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 17-35 587 DATE: May 17, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected posttraumatic stress disorder (PTSD) with traumatic brain injury (TBI) and/or gastroesophageal reflux disease (GERD), is denied. Entitlement to an initial rating of 70 percent, but no higher, for service-connected PTSD with TBI from August 7, 2017 is granted. Entitlement to a compensable initial rating for service-connected migraine headaches is denied. FINDINGS OF FACT 1. OSA did not have its onset in service and is not otherwise related to the Veteran's active military service. 2. OSA is not caused or aggravated by a service-connected disability, to include PTSD with TBI. 3. From the date of service connection, August 7, 2017, the Veteran's service-connected PTSD with TBI has been manifested by occupational and social impairment, with deficiencies in most areas, but has not more nearly approximated total occupational and social impairment. 4. From the date of service connection, August 7, 2017, the Veteran's service-connected migraine headache disability has been manifested by complaints of headache pain with sensitivity to light and sound; it has not been manifested by characteristic prostrating attacks. CONCLUSIONS OF LAW 1. OSA was not incurred in or aggravated by the Veteran's military service. 38 U.S.C. §§ 101, 1101, 1112, 1113, 1116, 1131, 1137, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 2. OSA is not proximately due to, or aggravated by, a service-connected disability. 38 U.S.C. §§ 1131, 5017; 38 C.F.R. §§ 3.303, 3.310(a). 3. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial disability rating of 70 percent, but no higher, for PTSD with TBI are met from the date of service connection. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code 9411. 4. The criteria for an initial compensable rating for migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 2009 to July 2009, November 2009 to August 2010, and April 2013 to April 2014. He is in receipt of the Combat Action Badge (CAB). This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated December 2016 and October 2017 of the Department of Veterans Affairs (VA) Regional Office (RO). The December 2016 rating decision denied service connection for OSA. The Veteran filed a notice of disagreement (NOD) in March 2017 and a statement of the case (SOC) was issued in April 2017. He perfected a timely appeal in June 2017. The October 2017 rating decision granted service connection PTSD with TBI and assigned a 50 percent rating from August 7, 2017. The rating decision also granted service connection for migraine headaches as secondary to TBI and assigned a noncompensable (zero percent) rating from August 7, 2017. The Veteran filed a NOD in November 2017. A SOC was issued in May 2018 and he perfected a timely appeal in June 2018. In February 2020, the Veteran presented sworn testimony during a videoconference hearing, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's VA claims file. In an April 2020 Board decision, the claims were remanded for further evidentiary development. In a January 2021 rating decision, the RO increased the assigned initial rating for PTSD with TBI to 70 percent from December 2, 2020. The Veteran has not expressed satisfaction with the increased initial rating; this matter thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). As will be detailed below, review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A supplemental statement of the case (SSOC) was issued in March 2021. The Veteran's VA claims file has been returned to the Board for further appellate proceedings. The April 2020 Board decision also remanded the matter of entitlement to service connection for plantar fasciitis of the right foot. In a March 2021 rating decision, the RO granted service connection for plantar fasciitis of the right foot and assigned a 10 percent rating. That matter has accordingly been resolved. See Grantham v. Brown, 114 F.3d 1136 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second NOD must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). 1. Entitlement to service connection for OSA, to include as secondary to service-connected PTSD with TBI and/or GERD. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or from or aggravation of a pre-existing injury suffered or disease contracted in line of duty. See 38 C.F.R. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board notes that there has been an amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Veteran asserts entitlement to service connection for OSA, which he contends was incurred during his military service. See the February 2020 Board hearing transcript. He alternatively contends that he developed OSA secondary to PTSD with TBI and/or GERD. Id. The Veteran contends that symptoms indicative of OSA began during his first deployment to Iraq from November 2009 to August 2010. See the Veteran's statement dated March 2017. He attributes his current OSA, first diagnosed in September 2016, to his exposure to burn pits and high concentrations of sand, dust, aircraft exhaust, and fuel fumes while on his active duty deployment to Iraq in 2009. Id. He reports no symptoms of sleep apnea before his deployment. Id. The Veteran's service treatment records (STRs) dated in August 2010 documented his report of problems sleeping. VA treatment records from August 2010 through October 2010 reveal that the Veteran was experiencing sleeping difficulties after his return from his November 2009 to August 2010 deployment, manifesting with lots of nightmares and moderate problems falling or staying asleep due to hypervigilance. He reported he "did not sleep at all" while on deployment. It was noted that he was taking sleep aids during this period. He reported at an October 2010 examination that these symptoms began after his May 2010 TBI. The Veteran made no reports about symptoms of snoring, or waking gasping for air, although he did report day-time fatigue. STRs show that the Veteran did not report any sleep issues on either his pre- or post-deployment questionnaire related to his second active duty deployment from April 2013 to April 2014. His April 2013 pre-deployment physical indicated that his sleep difficulty had resolved one year after his August 2010 separation from active duty. VA treatment records from this period indicate he was suffering symptoms of insomnia and was prescribed a sleep aid. Post-service treatment records dated in August 2016 noted that the Veteran exhibited witnessed apnea. He was diagnosed with moderate OSA syndrome in a September 2016 sleep study. At his February 2020 Board hearing, the Veteran reported that his sleep apnea symptoms began during his deployment to Iraq in 2009 and 2010. Specifically, he testified that after his traumatic injury in May 2010, his bunkmates began complaining to him about his snoring and would routinely wake him in the night because they were worried that he was not sleeping. He also testified that his spouse, whom he dated before his first deployment, told him that he did not have these symptoms prior to deploying, but that the symptoms were present after his return. In support of his contentions, the Veteran provided statements dated in February 2017 from two former bunkmates that served with him on this deployment that both indicated that the Veteran developed symptoms of loud snoring, gasping for air while sleeping, and daytime fatigue during this deployment. Both statements detail that the Veteran's symptoms began later in the deployment, with one detailing them beginning 6 months into the deployment, and the other indicating they began "halfway through" the deployment. One of these statements also asserts that the Veteran's symptoms continued during a second deployment to Afghanistan from April 2013 to April 2014. See the statement of S.S. dated February 2017. S.S. also asserts that the symptoms began after a grenade explosion involving the Veteran, which the bunkmate indicated occurred in May 2014. Id. This appears to be a typographical error though, as the Veteran's documented stressor incident related to a grenade explosion occurred in May 2010 and his records indicate he was not on active duty in May 2014. A May 2010 date would be more consistent with the report that the symptoms began "halfway through" the deployment. In support of his claim, the Veteran submitted a private medical opinion from Dr. R.T. dated in March 2018, which attributed the Veteran's OSA to his TBI residuals. Specifically, the examiner opined that it "is very likely that his TBI induced the onset of his OSA." In support of this opinion, Dr. R.T. cited to the lay statements presented by the Veteran's former bunkmates, finding them to be credible because of "the detail and specificity they articulate." Dr. R.T. also noted the Veteran's lay statements regarding his symptoms, although he did not address the discrepancies between the Veteran's reports of his own symptoms and symptom onset, and the symptoms and symptom onset reported by his former bunkmates. Dr. R.T. also did not discuss VA and service department treatment records, which indicate a resolution of any sleep problems that began after the May 2010 TBI about a year after the Veteran returned from that deployment. In providing a rationale for this opinion, Dr. R.T. cited a study titled "Sleep Apnea in Adults with Traumatic Brain Injury: A Preliminary Investigation" from the Archives of Physical Medicine and rehabilitation, Volume 82, Issue 3, found at https://www.archives-pmr.org/article/S0003-9993(01)02387-5/fulltext. Dr. R.T. summarized the study by stating that it shows "sleep related breathing disorders are very common in individuals with" TBI. Dr. R.T. followed that up by concluding that "in essence, sleep apnea symptoms can be brought on by a TBI." The Board finds this leap of logic by Dr. R.T. seems to confuse correlation with causation. Based on the representations made by Dr. R.T. regarding the article's contents, the Board finds that the rationale supporting this leap from a single study showing correlation to an opinion that there is a causative relationship is lacking and inadequate, as no explanation for this leap is given. Moreover, upon further inspection, the study described in the article itself found that "[n]o cause and effect relationship between TBI and sleep apnea can be established with this observational study design." Without further explanation by Dr. R.T., the Board finds this portion of the opinion inadequate. Further, the Board notes that the study cited in the article found more of an association between central sleep apnea, with which the Veteran has not been diagnosed, and TBI. The Veteran has, in fact, been diagnosed with OSA, not central sleep apnea. The study relied upon by Dr. R.T. also focused primarily on patients with recent TBI and did not address long-term, permanent sleep apnea related to TBI. In contrast, the Veteran was afforded VA medical opinions in October 2020 and December 2020. The October 2020 VA medical opinion indicated, "although the Veteran reported the onset of sleep apnea symptoms in 2009 while he was deployed to Iraq and the lay statements from Mr. R. and Mr. S. confirm his sleeping problems during their time together in service, STRs are negative for findings of sleep apnea issues and he did not report any sleep issues on either his pre or post deployment questionnaire related to his second active duty deployment from April 2013 to April 2014." The VA examiner further noted that the Veteran's "April 2013 pre-deployment physical shows that he reported his sleep difficulty had resolved one year after his August 2010 separation. The VA treatment records from August through October 2010 show sleep issues due to nightmares and hypervigilance but not due to snoring or waking up and gasping for air." The VA examiner noted that the private opinion from Dr. R.T. shows he related the Veteran's "OSA to his military service; however, the evidence from his service treatment records and VA treatment records shortly after separation do not support findings or symptoms of sleep apnea. The first diagnosis of obstructive sleep apnea was in September 2016, which was over 2 years after his separation from active duty." The examiner concluded, "[t]herefore, the Veteran's obstructive sleep apnea was less likely than not incurred in or caused by military service." In a December 2020 VA medical opinion, the VA examiner addressed the Veteran's contention of secondary service connection. The examiner stated, The medical opinion from Dr. Townsend dated 3/6/2018 shows he linked the Veteran's obstructive sleep apnea to his service connected TBI residuals. In providing a rationale for this opinion, the examiner cited a study titled "Sleep Apnea in Adults with Traumatic Brain Injury: A Preliminary Investigation" from the Archives of Physical Medicine and rehabilitation, Volume 82, Issue 3, found at https://www.archives-pmr.org/article/S0003-9993(01)02387-5/fulltext. The examiner summarized the study by stating that it shows "sleep related breathing disorders are very common in individuals with" TBI. A review of this opinion shows a correlation between central sleep apnea (not obstructive sleep apnea) and TBI. Correlation does not translate into causation. [The Veteran] has obstructive sleep apnea and not central sleep apnea. In any case, there is no evidence in this study that shows a direct causal relationship between TBI and the development of obstructive sleep apnea. [The Veteran's] obstructive sleep apnea was diagnosed in September 2016. However, there is no evidence or medical literature to support that his TBI directly caused obstructive sleep apnea. Therefore, the obstructive sleep apnea is less likely than not proximately due to his service connected TBI. In a separate December 2020 medical opinion, the VA examiner reported that he did not find any evidence to support the Veteran's contention that exposure to burn pit or other environmental hazards would cause sleep apnea. The examiner reported, "[a]ny airborne toxins are transitory and would not cause permanent changes in ones sleeping habits. While there's no doubt that he may [have] been exposed to fumes or dust in the Middle East is not a basis to cause sleep apnea." A VA addendum opinion was obtained in February 2021 to further address the Veteran's contentions of secondary service connection. The examiner stated, There is no evidence of OSA during service. The Veteran claims an onset during deployment in 2009. Official documents do not support that claim. The PDHA's on 8/11/10 and 11/7/10 are both negative for sleep disturbances, thereby negating that claim. The private opinion regarding GERD and OSA is incorrect. GERD is due to relaxation of the gastroesophageal junction/sphincter and is not caused by OSA. There is no anatomic or physiologic mechanism by which to do so. There is an association between GERD and OSA but cause has not been established in either direction. This is established medical knowledge and practice. The relationship is that both cause sleep disturbances and the sleep disturbance by GERD may make adjustment to CPAP more difficult and contribute to daytime fatigue. This is often misconstrued as cause and effect. This also does not represent aggravation of the baseline mechanism of OSA. Though not specifically asked, there is no evidence of aggravation of the Veteran's OSA beyond its natural course due to any cause, including GERD. As noted, OSA does not cause or aggravate GERD. TBI does not cause OSA. The study addressed by the Veteran has been misconstrued. First and foremost, the vast majority of sleep disturbances due to TBI are central in nature. This is established medical knowledge and is even addressed in the articles cited by the Veteran. The authors themselves note this is a preliminary study and does not establish cause. The central AHI component on the sleep study in 2016 was 0.0. Furthermore, central apnea would have manifest at the time of the injury or proximate to it, not six years after the event. Therefore, the Veteran's OSA is less likely than not (highly unlikely) due to the Veteran's TBI. Snoring, easy awakening, fitful sleeping, movements during sleeping, daytime somnolence/fatigue, insomnia, etc., are generalized symptoms and do not substantiate the diagnosis of OSA. The medical records in service cited above all address insomnia, nightmares and "sleep problems". These are, more likely than not related to psychological factors. Furthermore, prescriptions for zolpidem and trazodone for sleep further contradict the diagnosis of OSA while in service. Sleep aids such as these are not prescribed for OSA. They are generally prescribed for insomnia or related psychological comorbidities. In summary, the lay statements represent general sleep disorder symptoms and do not substantiate the diagnosis of OSA. It is less likely than not that the veterans OSA had its nexus in service or arose due to events in service, including the TBI. It is highly unlikely the TBI caused the Veteran's OSA. It is less likely than not that the OSA caused the Veteran's GERD or that the GERD caused the OSA. (The formal request appears to ask the dual question.) This also applies to aggravation, though not specifically asked. As noted, there is no evidence of aggravation beyond the natural course of the Veteran's OSA. CPAP adjustments are common in the natural course of the condition and do not necessarily represent aggravation beyond the natural course. The medical evidence does not support onset as due to or occurring in service, including the TBI. When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The United States Court of Appeals for Veterans Claims (Court) has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this matter, the Board recognizes that Dr. R.T. reported that the Veteran's OSA was incurred during his active duty service and/or his service-connected GERD and PTSD with TBI. However, this conclusion contrasts with the October 2020, December 2020, and February 2021 VA medical opinions, which specifically determined that the evidence does not support a finding that the Veteran's diagnosed OSA was incurred during his active duty service, or was caused or aggravated by his service-connected disabilities. To this end, the Board notes that the October 2020, December 2020, and February 2021 medical opinions were based on a review of the record, including the statements and evidence submitted by the Veteran, and the examiner explained the reasons for their conclusions based on an accurate characterization of the evidence of record. The examiner additionally addressed the March 2018 private opinion from Dr. R.T. and challenged the conclusions set forth therein. The Board therefore places significant weight on the cumulative findings expressed in the October 2020, December 2020, and February 2021 VA medical opinions. See Nieves-Rodriguez, supra; see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Accordingly, the Board finds that the competent medical evidence demonstrating the absence of nexus between the claimed OSA and the Veteran's active duty service, as well as his service-connected disabilities, outweighs any medical evidence suggestive of a nexus or aggravation. The Board has carefully considered the contentions of the Veteran that he has OSA, which was incurred during service and/or as secondary to his service-connected GERD and/or PTSD with TBI. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and 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 is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). In this case, the Veteran's assertions as to etiology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Questions of competency notwithstanding, the Veteran's lay theories regarding the onset and etiology of his OSA are contradicted by the conclusions set forth in the October 2020, December 2020, and February 2021 VA medical opinions, which specifically considered the Veteran's lay statements in rendering the negative opinions. The Board finds the specific, reasoned opinion of the trained health care provider who conducted the October 2020, December 2020, and February 2021 VA opinions to be of greater probative weight than the more general lay assertions of the Veteran. The Board has considered that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan, supra. Crucially, the October 2020, December 2020, and February 2021 VA medical opinions specifically considered the lay assertions and inferences contained in the record in rendering the negative nexus opinions. Considering the overall evidence, including the post-service medical evidence, the October 2020, December 2020, and February 2021 VA medical opinions, the private nexus opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran's contentions that he suffers from OSA, which is related to his military service and/or secondary to service-connected GERD and/or PTSD with TBI. Thus, the benefit-of-the-doubt rule is not applicable to the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. 2. Entitlement to an initial rating in excess of 50 percent prior to December 2, 2020 and 70 percent thereafter for service-connected PTSD with TBI. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, 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. When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claim. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. DC 8045 provides evaluation for three main areas of dysfunction that may result from traumatic brain injury and have profound effects on functioning: cognitive (which is common in varying degrees after a TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, DC 8045. Furthermore, emotional/behavioral dysfunction under § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. Id. This is the case here, as the issue in contention is the evaluation of the Veteran's PTSD from the TBI under 38 C.F.R. § 4.130, DC 9411, for evaluating PTSD. The Veteran has also been assigned a separate noncompensable (zero percent) initial rating for migraine headaches associated with PTSD with TBI and a 10 percent rating for tinnitus. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 , DC 9411 provides the following ratings for mental disorders: a 50 percent evaluation is for assignment when there is 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; difficulty establishing effective work and social relationships. Id. A 70 percent evaluation is contemplated for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, 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 as 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; inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent evaluation is warranted when there is evidence of 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 minimal personal hygiene; disorientation to time and place; memory loss for names of close relatives, own occupation or name. Id. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In this matter, the Veteran was granted service connection for PTSD with TBI in an October 2017 rating decision; a 50 percent disability rating was assigned effective from August 7, 2017. As indicated above, a January 2021 rating decision granted an initial rating of 70 percent for PTSD with TBI from December 2, 2020. For the reasons set forth below, the Board finds that a 70 percent rating, but no higher, is warranted from the date of service connection. VA treatment records included a psychiatry evaluation dated in July 2017, which indicated that the Veteran reported anxiety and PTSD, "affecting my relationship and I decided I needed to do something. I've been very short, certain things just set me off and get me very angry." He explained that, for at least the past eight years, he has noticed increased irritability, poor sleep, and recurrent dreams. The Veteran's spouse asked him to seek mental health treatment. The Veteran denied suicidal and homicidal ideation. He endorsed avoidance, detachment/estrangement from others, numbed feelings, difficulty sleeping, irritability with outbursts of anger, difficulty concentrating, nervousness/constantly on guard, easily started, and negative expectations. The VA treatment provided noted, "[c]ognitively, [the] Veteran appears to be functioning within normal limits." The Veteran was afforded a VA examination in August 2017 at which time the examiner confirmed diagnoses of PTSD and TBI. The examiner noted that the Veteran reported "significant cognitive processing issues which would be consistent from a sustained mild TBI." The examiner explained, "[i]t is likely that this individual's suspected mild TBI has exacerbated and amplified his PTSD symptoms." The examiner reported that the Veteran's PTSD with TBI manifests in "[o]ccupational 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 examiner noted that the Veteran's abilities to recognize and perceive emotions in others has likely been negatively impacted by his suspected mild TBI; his anxiety responses appear to be secondary to his PTSD. The examiner stated that the Veteran's "current levels of occupational and social impairment are likely being negatively impacted on a 50/50 basis with equal amounts attributable to each diagnosis." The examiner noted that the Veteran has a college degree and is employed full-time as a VA police training officer. The August 2017 VA examiner indicated that the Veteran endorsed re-experiencing traumatic events, avoidance, persistent and exaggerated negative beliefs or expectations, and markedly diminished interest or participation in significant activities. The Veteran additionally reported feelings of detachment or estrangement from others, persistent inability to experience positive emotions, irritable behavior with outbursts of anger, reckless or self-destructive behavior, exaggerated startle response, problems with concentration, and sleep disturbance. The Veteran further described depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, impaired abstract thinking, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and inability to maintain effective relationships. The examiner noted that the Veteran was anxious during the examination. He exhibited good hygiene, appropriate demeanor, and adequate social interaction skills. The examiner stated that "[n]o significant cognitive deficits [were] noted other than occasional word finding difficulties and attention and concentration impairment." The Veteran was afforded a VA TBI examination in September 2017 at which time the examiner confirmed the Veteran's history of TBI with current symptoms of forgetfulness and headaches. The examiner noted that the Veteran complains of mild memory loss "such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items." The Veteran also reported impaired attention, concentration, or executive functions; however, the examiner noted there was no objective evidence of this impairment on testing. The Veteran exhibited normal judgment. His social interaction is occasionally inappropriate as he does not like to socialize. The Veteran is always oriented to person, time, place, and situation. Hs motor activity is normal. His visual spatial orientation is normal. The Veteran had "[t]hree or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships." The examiner identified these subjective symptoms as dizziness, headaches, and insomnia. The Veteran exhibited "[o]ne or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them." The examiner identified these neurobehavioral effects as marital issues, mood swings, temper, and lack of motivation. The Veteran is "[a]ble to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language." He exhibited normal consciousness. The examiner reported that the Veteran's TBI does impact his ability to work; specifically, motivation, concentration, and forgetfulness are impacted. The examiner reported that he was unable to separate the Veteran's emotional and behavioral symptoms. In support of his claim, the Veteran submitted a June 2018 disability benefits questionnaire (DBQ) from Dr. E.T. in support of his higher initial rating claim. Dr. E.T. reported that the Veteran's PTSD with TBI manifests in "[o]ccupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood." The Veteran endorsed recurrent recollections and dreams, avoidance, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, restricted range of affect, difficulty falling or staying asleep, difficulty concentrating, hypervigilance, and exaggerated startle response. The Veteran additionally reported depressed mood, anxiety, near-conscious panic or depression affecting the ability to function independently, appropriately, and effectively, as well as chronic sleep impairment, mild memory loss, flattened affect, and disturbance of motivation and mood. The Veteran additionally exhibited difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, suicidal ideation, and impaired impulse control. A VA mental telehealth note dated in July 2018 noted the Veteran's chronic PTSD. The treatment provider indicated, "Veteran stated that he has periods where is okay, but then has times where he is not. He feels like his professional work is less impacted [than] his home life." VA treatment records dated in September 2019 noted that the Veteran's anxiety and irritability are somewhat better on medication. The Veteran described his interest in golf, T-ball with his son, and a recent vacation with his spouse for their anniversary. He indicated that he has long-term difficulty with short-term memory, ability to focus, and concentration. The Veteran hates being out in public and in crows. He experiences occasional flashbacks. The Veteran left his position with the VA police department and is now working as a homeowner's insurance adjuster. At the February 2020 Board hearing, the Veteran testified that he experiences suicidal ideation. See the Board hearing transcript, pg. 6. He reported that he left his career as a police officer as a result of his PTSD. Id. at pg. 5. The Veteran testified that he left the job due to irritability, not wanting to be around others, and emotional instability. Id. at pg. 16. His new job allows him to work from home. Id. The Veteran reported that he does not have any friends; he has one military friend with whom he maintains communication. Id. The Veteran reported that, as a police officer, he lashed out at partners and supervisees. Id. at pg. 17. The Veteran described difficulties with his spouse. Id. He stated that he throws things, punches things, and slams doors due to irritability with outbursts of anger. Id. He reported that, prior to him seeking mental health treatment, his spouse asked for a divorce. Id. Pursuant to the April 2020 Board Remand, the Veteran was afforded a VA psychological examination in December 2020. The examiner confirmed a diagnosis of PTSD with TBI. The examiner noted the Veteran's PTSD with TBI is manifested by "[o]ccupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood." The examiner reported that it is not possible to differentiate with occupational and social impairment is caused by PTSD versus TBI. The examiner reported that such symptoms significantly overlap and are difficult to disentangle. The Veteran has been married for six years. He reported that his relationship with his spouse is currently better. He endorsed a positive relationship with his two children. He reported that he often becomes irritable at family gathering. He reported that he ahs one close friend, but they recently had a falling out. The Veteran enjoys playing golf. However, he indicated that he does not often leave his home. The Veteran has worked full-time as an insurance adjustor for two years. He reported that he enjoys working from home. He reported that he has been reprimanded at work as a result of issues with irritability. The Veteran endorsed intrusive memories, dissociative reactions, distressing dreams related to stressors, negative thoughts about the world, avoidance, decreased interest in activities, feelings of detachment/isolation, irritability, hypervigilance, difficulty concentrating, and difficulty sleeping. He additionally described intermittent depressive symptoms, as well as occasional panic attacks that occur weekly or less often. The Veteran further reported mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances including work or a work-like setting, and suicidal ideation. The December 2020 VA examiner reported that the Veteran was cooperative and polite during the examination. His appearance was appropriate, and he was well-oriented. The Veteran exhibited an anxious affect congruent with his reported mood. The Veteran's concentration was intact. His immediate and remote memory were also intact. The Veteran's recent memory was somewhat impaired (he recalled two out of three words). The Veteran's thought processes were linear and goal-directed; his speech was within normal limits. He did not exhibit hallucinations/delusions or mania/hypomania. The Veteran described passive suicidal ideation, but denied plan or intent. The Veteran was afforded a VA TBI examination in December 2020 at which time the examiner noted the Veteran's report of impaired concentration and attention. He endorsed symptoms of headaches with photosensitivity and sensitivity to noise. The Veteran reported difficulty multi-tasking. The examiner noted the Veteran's complaint of mild memory loss, attention, concentration, or executive functions, but without objective evidence on testing. The Veteran's judgment was normal. His social interaction is routinely appropriate. He is always oriented to person, time, place, and situation. His motor activity is normal. His visual spatial orientation is normal. The Veteran exhibited three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships. The examiner explained that these subjective symptoms included irritability, sensitivity to light and sound, headaches, and difficulty with concentration and focus. The Veteran exhibited one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both, but do not preclude them. The examiner identified these neurobehavioral effects were irritability, impulsivity, inflexibility, and verbal aggression. The Veteran is "[a]ble to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language." He exhibited normal consciousness. The examiner reported that the Veteran's TBI impacts his ability to work. The examiner noted that the Veteran has been verbally counseled at work for his impulsivity, irritability, and verbal aggression. The Veteran has to write everything down to be productive, and finds it very difficult to multi-task, and take in multiple input of information. He has difficulty with concentration with reading, and difficulty with maintaining focus. The examiner reported that he is unable to differentiate what portion of each of the Veteran's symptoms are due to PTSD versus TBI. Based on the evidence of record, including that reported above, the Board finds that the impact of the Veteran's PTSD with TBI symptoms on his social and industrial functioning approximate the degree of impairment contemplated by a 70 percent rating from the date of service connection, August 7, 2017. As detailed above, the symptomatology associated with the Veteran's service-connected PTSD with TBI, to include that indicated by the lay statements and treatment records, supports the assignment of a 70 percent rating because this disability has been shown to result in occupational and social impairment, with deficiencies in most areas, such as work, family relations, and mood, due to such symptoms as near-continuous depression; anxiety; impaired impulse control, with periods of unprovoked irritability with outbursts of anger; difficulty in adapting to stressful circumstances, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work-like setting. 38 C.F.R. § 4.130, DC 9411. Specifically, these symptoms have been endorsed by the Veteran, as corroborated by VA and private examiners and VA treatment providers. Given the overall severity of the Veteran's psychological symptoms, the Board finds that the criteria for a 70 percent evaluation are met from the date of service connection. In addition, as set forth above, suicidal ideation is one of the symptoms associated with a 70 percent disability rating. Suicidal ideation involves a range from a passive wish not to awaken in the morning or a belief that others would be better off if the individual were dead, to transient but recurrent thoughts of committing suicide, to a specific plan. Bankhead v. Shulkin, 29 Vet. App. 10 (2017). The Court has held that the criteria for a 70 percent rating "indicates that the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas." Id. Given the evidence that the Veteran has reported a history of passive suicidal ideation throughout the appeal period, as well as the overall severity of the Veteran's psychological symptoms, the Board finds that the criteria for a 70 percent evaluation were met from the date of service connection. Significantly, the Veteran's symptoms have not more nearly approximated total occupational and social impairment at any point. 38 C.F.R. § 4.7. The evidence does not show total occupational and social impairment due to PTSD with TBI. There is evidence of significant occupational impairment due to his service-connected psychiatric disability. Critically, the Veteran has worked full time during the period herein under consideration. Moreover, there is no evidence of total social impairment. While the Veteran has generally been socially isolated, he maintains contact with his immediate family including his spouse and children. Total social impairment has therefore not been shown at any time from the date of service connection. As such, total occupational and social impairment was not demonstrated by the evidence. Furthermore, the Veteran has experienced intermittent suicidal ideation and irritability with outbursts of anger. Nevertheless, he has not exhibited any grossly inappropriate behavior, he has not exhibited memory loss for names of close relatives, own occupation, or name, he has remained fully oriented to time and place from the date of service connection, and he has generally been able to perform activities of daily living. Thus, he has not exhibited most of the symptoms listed in the examples for a 100 percent disability rating at any time from the date of service connection and total social and occupational impairment has not otherwise been demonstrated. In light of the above evidence and resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for a 70 percent, but no higher, rating for the service-connected PTSD with TBI have been met under the General Rating Formula from the date of service connection, August 7, 2017. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD with TBI, the evidence shows no distinct periods of time when the Veteran's service-connected disability varied to such an extent that a rating greater or less than 70 percent assigned herein would be warranted. Hart, supra. 3. Entitlement to an initial compensable rating for service-connected migraine headaches. The Veteran's migraine headache disability has been assigned a noncompensable rating under DC 8100, which contemplates migraine headaches. Under the applicable rating criteria, a 10 percent rating is assigned for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is assigned for migraines with characteristic prostrating attacks occurring on average once a month over the last several months. Finally, a maximum 50 percent rating is assigned for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. The Board observes that the rating criteria do not define "prostrating." Dorland's Illustrated Medical Dictionary defines "prostration" as "extreme exhaustion or powerlessness." See Dorland's Illustrated Medical Dictionary 1531 (32nd ed. 2012). Similarly, the rating criteria also do not define "severe economic inadaptability." However, the Court has indicated that, while there need not be a showing of unemployability, at a minimum, there should be an indication that the headaches are capable of interfering with the ability to earn money from work. Pierce v. Principi, 18 Vet. App. 440 (2004). As indicated above, the Veteran was granted service connection in an October 2017 rating decision, which assigned a noncompensable rating from August 7, 2017. He disagreed with the assigned initial disability rating and this appeal follows. For the reasons set forth below, the Board finds that a compensable initial rating for service-connected migraine headaches is not warranted. The Board initially notes that, at his pre-deployment physical in April 2013, the Veteran reported that his TBI symptoms had entirely subsided over a year prior and endorsed only mild headaches in past 2 weeks. He indicated that his symptoms were "occasionally present," but did "not disrupt activities." He reported that, at the time, the headaches occurred once weekly, manifesting with pain behind the eyes, rated as 3 out of 10, and without any associated nausea or vomiting. Headaches were not noted at his post-deployment physical in April 2014, and he reported no headaches to the National Guard or VA between April 2014 and his initial claim for service-connection for residuals of TBI in August 2017. The Veteran was afforded a VA examination in September 2017 at which time the examiner confirmed a diagnosis of migraine headaches with an onset after the in-service TBI. The examiner noted that the Veteran's "[h]eadaches have gradually become less frequent, but not clearly less severe." The Veteran reported headaches occurring twice a week manifested by constant pulsating or throbbing pain localized to one side of the head; pain worsens with physical activity. He endorsed non-headache symptoms of nausea, sensitivity to light and sound, and dizziness. The headaches last one to two days. The examiner indicated that the Veteran did not have characteristic prostrating attacks of migraine pain. The examiner further noted that the Veteran did not have very prostrating and prolonged attacks of migraine pain. The examiner reported that the Veteran's migraine headaches do not impact his ability to work. The Veteran submitted a private examination and opinion from March 2018 noting the same frequency and occurrence of symptoms described in the September 2017 VA examination report, but noting that those symptoms resulted in prostrating attacks of migraine headache pain more frequently than once per month. The private examiner also opined that the VA opinion did not make any sense because it was his opinion the symptoms were prostrating. The private examiner also indicated that the Veteran was incapable of doing anything when he had a severe headache, that he lies down with a pillow covering his head and that these events are incapacitating; however, an opinion does not seem to have been offered as to whether these headaches cause severe economic inadaptability as their effect on the Veteran's employment were not recorded. VA treatment records dated in November 2018 indicated that the Veteran reported migraine headaches occurring 2 or 3 times every couple of weeks, with no further explanation of types or severity of symptoms. The Veteran submitted logs of his headaches from January 2019 through July 2019. He reported eight headaches between January 29, 2019 and March 29, 2019, with 5 of them being prostrating. He also reported 15 headaches between April 1, 2019 and July 27, 2019, with none of them noted as prostrating. Per the Veteran's report, all headaches lasted between 4 and 15 hours, most involved constant pain, although some manifested with throbbing pain, most affected the left side of the head, and most involved some combination of sensitivity to light and sensitivity to sound, with additional variations of the symptoms of nausea, changes in vision, and sensory changes. The Veteran's most common treatment methods recorded included taking Ibuprofen or using medicinal marijuana. Headache logs for the entire period on appeal have not been submitted to the record. At the February 2020 Board hearing, the Veteran reported migraines about once a week, or 3 to 4 times a month, noting that they lasted in severity from a day to 2-3 days. See the Board hearing transcript, pg. 13. The Veteran stated that he could not do anything when he has a migraine, that they cause him to be unable to function, cause sensitivity to light and noise, and feel like a pounding in his head. Id. The Veteran reported that these migraine headaches were a factor in him leaving his position as a police officer with the VA and taking a job as an insurance adjuster that allowed him to work from home. Id. at pg. 14. He testified that he began using medical marijuana after his job switch and did not use medical marijuana while he was a VA police officer. Id. The Veteran was still working fulltime at the time of his Board hearing, and reported that he had adapted to working from home, as it was an accomodation that allowed him some time to recover when he developed headache symptoms. Id. VA treatment records dated in August 2020 noted the Veteran's report of migraine headaches that occur once per week. The Veteran reported that the headaches are located on the left side of his head in the frontal/parietal region. His headache pain is 7/10; sound and light are aggravating. The Veteran indicated that Sumatriptan provides some relief. Pursuant to the April 2020 Board remand, the Veteran was afforded a VA examination in October 2020 to address the nature and severity of his service-connected migraine headaches. The Veteran reported that his headaches are treated with Sumatriptan. Headache pain is localized to one side of the head with sensitivity to light and sound. The duration of the headaches is less than one day. The examiner indicated that the Veteran does not have characteristic prostrating attacks of migraine headache pain. He also does not have very prostrating and prolonged attacks of headache pain productive of severe economic inadaptability. The VA examiner explained, "[t]he results from today's examination show a diagnosis of migraine headaches; however, the presentation and description of his headaches does not show the Veteran's headaches are prostrating." The examiner continued, "[t]he evidence since the beginning of the appeal period, to include prior examinations, the BVA Board hearing, VA treatment records, and his private headache logs, do not support consistent findings of prostrating headaches, which would fluctuate in severity from findings on today's examination." Accordingly, based on a review of the evidence, the Board finds that the preponderance of the evidence is against the assignment of an initial compensable for the Veteran's migraine headache disability. As detailed above, the Veteran's headache disability has been manifested by headache pain with sensitivity to light and sound. The Board recognizes that the Veteran has reported experiencing prostrating headaches and the March 2018 DBQ from Dr. R.T. characterized the Veteran's headaches as prostrating. However, these reports are not supported by the medical evidence of record. The Veteran's VA and private treatment records do not corroborate his assertions of prostrating headache symptoms. Moreover, the October 2020 VA examiner reviewed the evidence of record and specifically reported that the evidence of record does not demonstrate that the Veteran has experienced prostrating headaches during the appeal period. The examiner reviewed the Veteran's medical history and provided rationale in support of the conclusion rendered. The Board therefore places significant weight on the findings of the October 2020 VA examiner. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) ("It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion."); see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). The Board therefore finds that the probative evidence of record does not support a finding that a compensable initial rating is warranted for the service-connected migraine headaches. In addition, the evidence does not show that the Veteran's migraine headache symptoms are productive of severe economic inadaptability. The Veteran reported that he took time off from previous work as a policeman due to his migraine headache symptoms. See the February 2020 Board hearing transcript, pg. 14. Significantly, the evidence also shows that, despite his headache disability, the Veteran continued to work. The fact that the Veteran occasionally misses work is not reflective of symptoms more nearly approximating severe economic inadaptability. While the phrase "productive of severe economic inadaptability" in DC 8100 should be construed to include "capable of producing" severe economic inadaptability, the Board finds that the Veteran's migraine headaches are not capable of producing severe economic inadaptability at this juncture. Crucially, he has continued his employment and to date, his headaches have not been shown to produce or be capable of producing severe economic inadaptability. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected migraine headaches, the evidence shows no distinct periods of time throughout the appeal period, when his disability varied to such an extent that a compensable rating would be warranted. Hart, supra. For the reasons set forth above, the Board finds that the preponderance of the evidence is against the assignment of an initial compensable rating for the Veteran's service-connected migraine headache disability. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C. § 5107(b). K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. K. Buckley, 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.