Citation Nr: A25041276 Decision Date: 05/06/25 Archive Date: 05/06/25 DOCKET NO. 210927-188178 DATE: May 6, 2025 ORDER 1. Entitlement to service connection for major depressive disorder with panic attacks, generalized anxiety disorder, alcohol use disorder and cannabis use disorder is granted. 2. Entitlement to service connection for chronic fatigue syndrome is denied. 3. Entitlement to service connection for irritable bowel syndrome with functional abdominal pain syndrome and bloating is denied. 4. Entitlement to an evaluation of 50 percent, but no higher, for service-connected migraine headaches for the entire period is granted. 5. Entitlement to an evaluation in excess of 50 percent for migraine headaches is denied. FINDINGS OF FACT 1. The evidence of record is at least in approximate balance that the Veteran's major depressive disorder with panic attacks, generalized anxiety disorder, alcohol use disorder and cannabis use disorder began during active service or is otherwise related to an in-service injury or disease. 2. The evidence of record persuasively weighs against finding that the Veteran has chronic fatigue syndrome related to service. 3. The evidence of record persuasively weighs against finding that the Veteran has irritable bowel syndrome with functional abdominal pain syndrome and bloating related to service. 4. The evidence of record is at least in approximate balance that for the entire period on appeal, the symptoms of the Veteran's migraine headaches more nearly approximate very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. 5. The Veteran is in receipt of a 50 percent disability rating for service-connected migraine headaches for the entire period on appeal; factors warranting referral of the claim for consideration of an extraschedular increased rating are not shown. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for major depressive disorder with panic attacks, generalized anxiety disorder, alcohol use disorder and cannabis use disorder have been met. 38 U.S.C. §§ 1110, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.104, 3.303. 2. The criteria for entitlement to service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1110, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for irritable bowel syndrome with functional abdominal pain syndrome and bloating have not been met. 38 U.S.C. §§ 1110, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to an evaluation of 50 percent for service-connected migraine headaches for the entire period on appeal have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1- 4.7, 4.14, 4.120, 4.124a, DC 8100. 5. The criteria for entitlement to an evaluation in excess of 50 percent for service-connected migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1- 4.7, 4.14, 4.120, 4.124a, DC 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Navy from June 1989 to June 1993 and June 1993 to February 1995. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2021 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA), the Agency of Original Jurisdiction (AOJ). In the September 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the August 2021 AOJ decision on appeal, as well as any evidence submitted by the Veteran [or representative] with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the persuasive weight of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to establish direct service connection, a veteran must show: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be satisfied before direct service connection may be achieved. Service connection may also be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 U.S.C. §§ 1113(b); 38 C.F.R. § 3.303(d). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110. Even in the absence of a diagnosed disability, evidence of functional limitations due to symptoms can meet this requirement. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Specifically, in Saunders, the Federal Circuit found that the term "disability," as used in 38 U.S.C. § 1110 refers to the functional impairment of earning capacity, not the underlying cause of said disability, and held that pain alone can serve as a functional impairment and therefore qualify as a disability. Under 38 C.F.R. § 3.317, service connection may be granted on a presumptive basis if there is evidence (1) that the claimant is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multisymptom illness (MUCMI) (such as chronic fatigue syndrome, fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317. Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the persuasive weight of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). 1. Entitlement to service connection for major depressive disorder with panic attacks, generalized anxiety disorder, alcohol use disorder and cannabis use disorder is granted. The Veteran seeks entitlement to service connection for major depressive disorder with panic attacks, generalized anxiety disorder, alcohol use disorder and cannabis use disorder (hereafter MDD/GAD) which he attributes to active duty service. See September 2021 VA Form 10182; May 2021 VA 21-526EZ. As an initial matter, the current disability element of the Veteran's claim is not in dispute. In its August 2021 rating decision, the AOJ found that private treatment records show a diagnosis of major depressive disorder, recurrent, severe without psychotic features, generalized anxiety disorder, alcohol use disorder, and cannabis use disorder. See August 2021 Rating Decision - Narrative, at 4. Under the AMA, the Board is bound by favorable findings by the AOJ in the absence of evidence of clear and unmistakable error. 38 C.F.R. § 3.104(c). Thus, the first element of direct service connection, the presence of a current disability, is met. See Shedden, 381 F.3d at 1167. The second element of direct service connection requires an in-service incurrence. The Veteran contends that his MDD/GAD stems from being court martialed and forced to voluntarily end his military career or else be dishonorably discharged. Military personnel records (MPRs) indicate that the Veteran was considered for an administrative separation from the naval service by reason of misconduct due to the commission of a serious offense. See June 2021 MPR, at 29-31, 64-65, 81-82. Thus, the second element of direct service connection, an in-service incurrence, is also met. See Shedden, 381 F.3d at 1167. Turning to the final element of direct service connection, the Board must determine whether there is a nexus between the Veteran's current MDD/GAD and his active duty service. See Shedden, 381 F.3d at 1167. First, the Board turns to the Veteran's service treatment records (STRs) which are negative for any symptoms, treatment and diagnosis related to any psychiatric or mental health condition. The Veteran's June 1989 service enlistment examination and January 1995 separation examination reports show clinically normal findings for depression or excessive worry, sleep troubles, loss of memory or amnesia, and nervous trouble of any sort. See October 2018 STR, at 15, 21. In May 2021, the Veteran submitted a Report of Consultation and Examination from a private diagnostic consultant, Dr. M.T. The report was dated April 8, 2021. The Veteran reported that he has suffered panic attacks without attending chest pains and has been progressively symptomatic since Gulf War service without hiatus. Dr. M.T. diagnosed the Veteran with panic attacks without attending chest pain. See May 2021 DBQ, at 3. Dr. M.T. opined that "it is as likely as not that the aforementioned is directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illness) published in Gulf War. Winter 2016. www.publichealth.va.gov." See May 2021 DBQ, at 3. It is as likely as not that same is directly and causally related to the Veteran's military service. This is a permanent condition which had its onset during deployment to The Southwest Asia Theater of Military Operations and has persisted to the present. Id. The Board finds this private medical opinion insufficient for adjudication purposes. First, the Board acknowledges that the private opinion contained a hyperlink to content that is not otherwise part of the record on appeal; however, that content was not accessed nor considered as part of the record before the Board. See Bowey v. West, 11 Vet. App. 106, 108-09 (1998) (holding that the mere reference to non-VA documents is insufficient to incorporate them into the record). Second, the Board cannot rely on this opinion as the private clinician offered no more than a conclusory rationale for her conclusions without any analysis other than to refer to a general hyperlink. Without any context to justify her reasoning, it is not possible to evaluate the validity of Dr. M.T.'s conclusions. In May 2021, the Veteran submitted a Psychological Evaluation from a private psychologist, Dr. A.N. The report was dated April 8, 2021. The Veteran reported that his mental health symptoms began with court martials during active service. The Veteran had hopes of retiring from the Navy and felt forced to voluntarily separate from service to avoid dishonorable discharge. See May 2021 DBQ, at 6. The Veteran reported having bad dreams, prolonged psychological distress at cues that resemble his negative experience in the Navy, avoids talking about the military, avoids situations that remind him of the Navy, has exaggerated negative beliefs and expectations of the world, himself, and others, markedly diminished interest and participation in significant activities, feelings of detachment and estrangement from others, feelings of guilt, shame, problems with concentration, sleep disturbance, is hypervigilant, and has an exaggerated startle response. The Veteran indicated that he has panic attacks, depressed mood, low appetite, and persistent worry. Dr. A.N. also collected lay statements from the Veteran's sister and fiancé who described the Veteran as having mood swings, being distant, having anger problems, that he "snaps," has angry "outbursts," does not sleep, keeps busy to avoid sleep, appears to be depressed, and sometimes does not even eat. Id., at 7. Dr. A.N. administered the Minnesota Multiphasic Personality Inventory (MMPI-2), the Beck Depression Inventory-II (BDI-II), and the Beck Anxiety Inventory (BAI) Id., at 9-10. The Veteran was diagnosed with major depressive disorder, recurrent, severe without psychotic features, generalized anxiety disorder, severe alcohol use disorder and mild cannabis use disorder. Id., at 11. Dr. A.N. opined the Veteran's generalized anxiety disorder and major depression are at least as likely as not stemming from the end of his military career, when he was forced to choose to dishonorably discharge or voluntarily discharge honorably. Dr. A.N. also opines that the Veteran's alcohol and marijuana issues stem from the same time, because he started to use these substances to cope with anxiety and depressive symptoms. Id. As rationale, Dr. A.N. explained that the Veteran had no mental health issues in childhood, and there is no known family mental health history. The Board affords significant probative weight to this private opinion. The private opinion was provided by a qualified medical professional who conducted in-person evaluations and psychological testing, consideration of lay statements from the Veteran and two family members, application of the facts to current medical knowledge, and with a very detailed rationale to support their findings. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Further, the Board has fully reviewed the electronic claims file and finds no other competent evidence to the contrary. Based on the foregoing, the Board finds that the competent and credible evidence persuasively weighs in favor of finding that the Veteran's MDD/GAD is related to an in-service injury, event, or disease. Accordingly, the benefit of the doubt doctrine is therefore not for application as to this claim. 38 U.S.C. §5107(b), Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021), affirmed en banc Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). The Veteran's appeal is granted. 2. Entitlement to service connection for chronic fatigue syndrome is denied. The Veteran seeks entitlement to service connection for chronic fatigue syndrome (hereafter CFS) which he attributes to active duty service. See September 2021 VA Form 10182; May 2021 VA 21-526EZ. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the evidence of record persuasively weighs against finding that the Veteran's claimed CFS began during active service, or is otherwise related to an in-service injury, event, or disease, as supported by the analysis below. As a preliminary matter, the Board notes that the record contains contradicting medical opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (stating that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board will consider each of the opinions below. First, the Board turns to the Veteran's service treatment records (STRs) which are silent for any complaints, treatment, and diagnosis of chronic fatigue, and related symptomology. The Veteran's June 1989 service enlistment examination and January 1995 separation examination reports show clinically normal findings. See October 2018 STR, at 15, 21. In May 2021, the Veteran submitted a Report of Consultation and Examination from a private diagnostic consultant, Dr. M.T. The report was dated April 8, 2021. The Veteran stated he suffered with CFS since active duty without hiatus. Dr. M.T. diagnosed the Veteran with CFS. Dr. M.T. opined that "it is as likely as not that the aforementioned is directly and causally related to Gulf War Syndrome per the provisions published in Gulf War. Winter 2016. www.publichealth.va.gov." See May 2021 DBQ, at 2-3. It is as likely as not that same is directly and causally related to the Veteran's military service. This is a permanent condition which had its onset during deployment to The Southwest Asia Theater of Military Operations and has persisted to the present. Id. The Board finds this private medical opinion insufficient for adjudication purposes. As noted above, the Board acknowledges that the private opinion contained a hyperlink to content that is not otherwise part of the record on appeal; however, that content was not accessed nor considered as part of the record before the Board. See Bowey v. West, 11 Vet. App. 106, 108-09 (1998) (holding that the mere reference to non-VA documents is insufficient to incorporate them into the record). Also, the Board observes that the private opinion is bereft of any discussion of any specific onset and/or symptoms of CFS that the Veteran experienced during active service. Therefore, Dr. M.T.'s statements are unpersuasive as they do not address any facts specific to this Veteran or criteria considered in making the CFS diagnosis. In August 2021, the Veteran was afforded a VA Chronic Fatigue Syndrome examination. The VA examiner indicated that a complete review of the Veteran's claims file and in-person examination were conducted. The Veteran indicated that his CFS began in the 1990's with symptoms of fatigue, feeling tired, and lack of energy which he treated with vitamins. See August 2021 CFS C&P, at 2. Current symptoms are chronic fatigue, feeling tired and lack of energy almost daily until he gets started moving. The Veteran reported normally getting less than 3 hours of sleep per night. Id. The VA examiner indicated that other conditions such as insomnia and anxiety may produce similar symptoms. The VA examiner found that the Veteran does not now have or has had any findings, signs, and symptoms attributable to CFS. The VA examiner found no pathology to render a diagnosis for this condition as the Veteran did not meet the criteria for CFS; thus, no nexus was established. Id., at 5; August 2021 CFS Opinion, at 4. The Board again acknowledges the positive opinion provided by private clinician Dr. M.T. in May 2021. However, as discussed above, Dr. M.T. offered no rationale for concluding that the Veteran has CFS that is related to active duty service. Thus, the Board assigns more probative weight to the August 2021 VA medical opinion where the VA examiner reviewed the Veteran's claims file and VA electronic health records, considered lay evidence from the Veteran, conducted an in-person examination, and provided a detailed rationale to support their findings. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As described above, the first prong of a service connection claim is a current disability. The evidence of record does not demonstrate that the Veteran has had CFS during the pendency of the appeal. While the Veteran believes that his fatigue is related to active service, he has not been shown to have the requisite medical knowledge and expertise to be deemed competent to provide a diagnosis or nexus opinion in this case. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, the Board gives more probative weight to the competent medical evidence of record, which fails to identify any current compensable CFS condition. As noted above, the Board is cognizant of Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018), wherein the Court held that, in some cases, symptoms alone without a clinical diagnosis can constitute a disability for VA purposes when such symptoms amount to functional impairment of earning capacity. However, the Veteran has not provided evidence that he has current a compensable CFS condition that resulted in impairment in work or in earning capacity. Thus, in the absence of any impairment of ability to work, the evidence of record does not show that the Veteran's claimed CFS results in functional impairment of earning capacity. The first and perhaps most fundamental requirement for any service-connection claim, on either a direct or secondary basis, is proof that the Veteran has a current disability. 38 U.S.C. § 1132; 38 C.F.R. § 3.303(a); Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997). In the absence of proof of a current disability, there can be no valid claim. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of any credible and competent evidence tending to show that the Veteran has a diagnosis related to CFS, or that chronic fatigue causes functional limitations, service connection for CFS is not warranted. Further, as noted above, the medical evidence relates the Veteran's fatigue symptoms to known disabilities to include insomnia and anxiety. Consequently, the Board finds that service connection under 38 U.S.C. § 1117(g) is not warranted, to include as an undiagnosed illness. As the weight of the evidence is persuasively against the Veteran's claim, the doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). As such, the Veteran's service connection claim for CFS is denied. 3. Entitlement to service connection for irritable bowel syndrome (IBS) with functional abdominal pain syndrome and bloating is denied. The Veteran seeks entitlement to service connection for irritable bowel syndrome with functional abdominal pain syndrome and bloating (hereafter IBS) which he attributes to active duty service. See September 2021 VA Form 10182; May 2021 VA 21-526EZ. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the evidence of record persuasively weighs against finding that the Veteran's claimed IBS began during active service, or is otherwise related to an in-service injury, event, or disease, as supported by the analysis below. As a preliminary matter, the Board notes that the record contains contradicting medical opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (stating that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board will consider each of the opinions below. First, the Board turns to the Veteran's service treatment records (STRs) which are silent for any complaints, treatment, and diagnosis of any gastrointestinal issues. The Veteran's June 1989 service enlistment examination and January 1995 separation examination reports show clinically normal findings for stomach, liver, or intestinal trouble. See October 2018 STR, at 15, 21. In May 2021, the Veteran submitted a Report of Consultation and Examination from a private diagnostic consultant, Dr. M.T. The report was dated April 8, 2021. The Veteran stated he suffers from IBS via intermittent constipation and diarrhea which has been present since Gulf War service without hiatus. No diagnosis was listed, but Dr. M.T. opined "it is as likely as not that the aforementioned is directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illness) published in Gulf War. Winter 2016. www.publichealth.va.gov." See May 2021 DBQ, at 3. It is as likely as not that same is directly and causally related to the Veteran's military service. This is a permanent condition which had its onset during deployment to The Southwest Asia Theater of Military Operations and has persisted to the present. Id. With regard to functional abdominal pain syndrome/abdominal pain and bloating, the Veteran stated that he suffered with this condition which has been present since Gulf War service without hiatus. No diagnosis was listed, but Dr. M.T. opined "it is as likely as not that the aforementioned is directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illness) published in Gulf War. Winter 2016. www.publichealth.va.gov." See May 2021 DBQ, at 3. It is as likely as not that same is directly and causally related to the Veteran's military service. This is a permanent condition which had its onset during deployment to The Southwest Asia Theater of Military Operations and has persisted to the present. Id. The Board finds this private medical opinion insufficient for adjudication purposes. First, the Board acknowledges that the private opinion contained a hyperlink to content that is not otherwise part of the record on appeal; however, that content was not accessed nor considered as part of the record before the Board. See Bowey v. West, 11 Vet. App. 106, 108-09 (1998) (holding that the mere reference to non-VA documents is insufficient to incorporate them into the record). Second, the Board cannot rely on this opinion as the private clinician offered no more than a conclusory rationale for her conclusions without any analysis other than to refer to a general hyperlink. Without any context to justify her reasoning, it is not possible to evaluate the validity of Dr. M.T.'s conclusions. In August 2021, the Veteran was afforded a VA Intestinal Conditions examination. The VA examiner indicated that a complete review of the Veteran's claims file and in-person examination were conducted. The Veteran indicated that his IBS began in the 1990's with symptoms of bloating, gas, and abdominal pain. See August 2021 IBS C&P, at 2. Current symptoms are some discomforts of the upper abdomen, no diarrhea, no constipation, and no blood in stool. Id. The VA examiner indicated that the Veteran does not have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestines, does not have weight loss attributable to an intestinal condition, does not have malnutrition, or a benign or malignant neoplasm or metastases. Id., at 3-4. The VA examiner indicated that "[f]or the claimant's claimed condition of Irritable Bowel Syndrome there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis." Id., at 5. The examination was normal with no objective findings; thus, no nexus was established. The Board again acknowledges the positive opinion provided by private clinician Dr. M.T. in May 2021. However, as discussed above, Dr. M.T. offered no rationale for concluding that the Veteran has IBS that is related to active service. Therefore, the Board assigns more probative weight to the August 2021 VA medical opinion where the VA examiner reviewed the Veteran's claims file and VA electronic health records, considered lay evidence from the Veteran, conducted an in-person examination, and provided a detailed rationale to support their findings. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As described above, the first prong of a service connection claim is a current disability. The evidence of record does not demonstrate that the Veteran has had IBS during the pendency of the appeal. While the Veteran believes that his symptoms are related to active duty service, he has not been shown to have the requisite medical knowledge and expertise to be deemed competent to provide a diagnosis or nexus opinion in this case. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, the Board gives more probative weight to the competent medical evidence of record, which fails to identify any current compensable IBS condition. As noted above, the Board is cognizant of Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018), wherein the Court held that, in some cases, symptoms alone without a clinical diagnosis can constitute a disability for VA purposes when such symptoms amount to functional impairment of earning capacity. However, the Veteran has not provided evidence that he has current a compensable IBS condition that resulted in impairment in work or in earning capacity. Thus, in the absence of any impairment of ability to work, the evidence of record does not show that the Veteran's claimed IBS results in functional impairment of earning capacity. The first and perhaps most fundamental requirement for any service-connection claim, on either a direct or secondary basis, is proof that the Veteran has a current disability. 38 U.S.C. § 1132; 38 C.F.R. § 3.303(a); Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997). In the absence of proof of a current disability, there can be no valid claim. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of any credible and competent evidence tending to show that the Veteran has a diagnosis related to IBS, or that symptom causes functional limitations, service connection for IBS is not warranted. Although service connection on a presumptive basis is available for IBS for Gulf War veterans, the Veteran has not been diagnosed with IBS or any other functional gastrointestinal disorder. Indeed, during the August 2021 VA examination the Veteran reported some discomforts of the upper abdomen, no diarrhea, no constipation, and no blood in stool. As the weight of the evidence is persuasively against the Veteran's claims, the doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). As such, the Veteran's service connection claim for IBS is denied. 4. Entitlement to an evaluation of 50 percent, but no higher, for migraine headaches for the entire period is granted. 5. Entitlement to an evaluation in excess of 50 percent for migraine headaches is denied. The Veteran seeks an evaluation in excess of 50 percent for service-connected migraine headaches. See September 2021 VA Form 10182; May 2021 VA 21-526EZ. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation 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 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 entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1. Where service connection has already been established, and an increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). The Board must assess the credibility and weight of all 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. 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. In its July 2021 rating decision, the RO granted service connection for migraine headaches with a 0 percent evaluation effective March 2, 2021. The Veteran's noncompensable rating for migraine headaches was based on less frequent attacks. In August 2021, the RO assigned a 50 percent evaluation for migraine headaches effective August 5, 2021. The Veteran's current 50 percent disability rating is based on very frequent completely prostrating and prolonged attacked productive of severe economic inadaptability. The Veteran's migraines are rated pursuant to 38?C.F.R. §?4.124a, Diagnostic Code (DC) 8100. Under DC 8100, a 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. This is the highest schedular evaluation allowable under the law for migraine headaches. 38 C.F.R. § 4.120. The rating criteria under DC 8100 are successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. See Johnson v. Wilkie, 30 Vet. App. 245, 247 (2018). Additionally, the phrase "characteristic prostrating attacks" plainly describes migraine attacks that typically produce powerlessness or a lack of vitality. 30 Vet. App. at 252. In May 2021, the Veteran submitted a Report of Consultation and Examination from a private diagnostic consultant, Dr. M.T. The report was dated April 8, 2021. The Veteran reported suffering from chronic headaches since active duty service without hiatus. Here, the Veteran was diagnosed with chronic headaches. Dr. M.T. noted that the Veteran suffers three (3) or more headaches per week with an average duration of 2-4 hours depending on how quickly he can medicate and how efficient the medication is when taken. See May 2021 DBQ, at 3. In July 2021, the Veteran was afforded a VA examination for headaches, including migraine headaches. The VA examiner indicated a complete review of the Veteran's claims file and in-person examination were conducted. Here, the Veteran was diagnosed with migraine (including migraine variants). See July 2021 Headache C&P, at 2. The Veteran reported that he started having headaches when he was deployed in Africa on a survey ship where he was treated with Ibuprofen. Id., at 3. The Veteran stated he did not follow up with the VA due to the long wait and no transportation, in addition to no medical insurance. Id. With regard to symptoms, the Veteran stated that his tension headaches are usually triggered by having to rush things and stress. The Veteran stated his eyes are always red, vision is blurry and his eyes feel heavy. The Veteran reported having an average of 4 headaches per day, with a 10/10 pain level. Id. The VA examiner noted symptoms of constant head pain, changes in vision, pain in the area of the eyes and just above, lasting less than a day with characteristic prostrating attacks of migraine. Id., at 5-6. The Veteran reported that he was self-employed washing cars and that his headaches caused him to lose 2-4 weeks of work time in the last 12 months. Id., at 7. In August 2021, the Veteran was afforded another VA examination for headaches, including migraine headaches. The VA examiner indicated a complete review of the Veteran's claims file and in-person examination were conducted. Here, the Veteran was diagnosed with tension headaches. See August 2021 Headache C&P, at 2. The Veteran reported that he started having headaches in the 1990s and is currently treated with Aleve. Id., at 2. With regard to symptoms, the Veteran stated that his whole head hurts, it bothers him and hurts over his eyes. Id. The Veteran reported pulsating or throbbing head pain, pain on both sides of head, tightness, lasting less than one day on both sides of the head, with characteristic prostrating attacks of migraine once every month. Id., 2-3. During severe episodes of headaches, the Veteran has difficulty performing overall physical work activities. Id., at 4. Based on a review of the evidence detailed above, the Board finds that for the entire period on appeal, the Veteran's tension and migraine headaches have resulted in frequent, prostrating, and prolonged attacks productive of severe economic inadaptability, that last less than 1 day per occurrence, but may occur multiple times per day as first reported at the July 2021 VA examination. In reaching this conclusion, the Board considered the symptoms marked on the VA Headache Disability Benefits Questionnaires' (DBQ) checklist, as well as the written narrative outlining the frequency and severity of the Veteran's symptoms. Nevertheless, the Board further finds that these symptoms are contemplated by the currently assigned maximum rating of 50 percent, as the rating criteria for migraine headaches are based on the frequency of the headaches and whether the headache, and its associated symptoms, results in prostration. See Holmes v. Wilkie, 33 Vet. App. 67 (2020). Thus, DC 8100 inherently considers all symptoms associated with a headache disability, in that it focuses only on the frequency of any and all symptoms and whether those symptoms result in prostration. Id. The Veteran has only been diagnosed with tension and migraine headaches during the relevant appeal period, which are specifically covered by DC 8100. As such, it would be inappropriate to rate by analogy to any other diagnostic codes. See Copeland v. McDonald, 27 Vet. App. 333, 33637 (2015) (stating that when a condition is specifically listed in the schedule, it may not be rated by analogy). Accordingly, consideration of any alternative diagnostic codes, and any potentially higher ratings associated with alternative diagnostic codes, is not warranted. Given that the Veteran has already been assigned the maximum schedular rating for migraine headaches under DC 8100, a higher schedular rating is not available. Thus, the Board finds that there is no basis upon which to award the Veteran an increased evaluation in excess of 50 percent for migraines. The Board has also considered whether the Veteran may be entitled to an increased evaluation in excess of 50 percent for migraines on an extraschedular basis. In the exceptional case when the schedular evaluation is inadequate to rate a single service-connected disability, the matter is to be referred to the Director of Compensation (or a delegate) for consideration of an extraschedular rating commensurate with the average impairment of earning capacity due exclusively to the disability. The governing norm in such cases is that the disability is exceptional or unusual due to such factors such as marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 114 (2008); aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). These criteria have been broken up into two elements: (1) The schedular criteria must be inadequate to describe the claimant's disability level and symptomatology and (2) there must be related factors such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. 111, 114 (2008); Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009). If both elements are met, the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the claimant's disability picture requires the assignment of an extraschedular rating. See Thun, 22 Vet. App. at 116; 38 C.F.R. § 3.321(b). If either element is not satisfied, then referral is not warranted. See Yancy v. McDonald, 27 Vet. App. 484, 494-95 (2016). The Board finds that the first Thun element is not satisfied here. The Veteran states that his headaches manifest as pulsating or throbbing head pain, pain on both sides of head, tightness, changes in vision, pain in the area of the eyes and just above, lasting less than a day with characteristic prostrating attacks of migraine, occurring up to 4 times per day. The Veteran further reported that these attacks can be completely prostrating and are productive of severe economic inadaptability. The Veteran's symptoms, and their resulting impairment, are contemplated by the Rating Schedule for migraine headaches under DC 8100. As outlined above, the Veteran has been afforded the highest rating possible for migraines. In short, the evidence does not indicate that the Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria. There is nothing exceptional or unusual about the Veteran's service-connected headache disability because the rating criteria reasonably describe his disability level and symptomatology. See Thun, 22 Vet. App. at 115. In view of the adequacy of the disability rating assigned under the applicable diagnostic criteria, consideration of the second step under Thun is not for application in this case. As such, the evidence of record does not warrant referral for consideration of an extra-schedular rating. Based on the foregoing, the Board finds that the competent and credible evidence persuasively weighs in favor of finding that a disability evaluation of 50 percent, but no higher, for migraine headaches is warranted for the entire period on appeal. However, a disability evaluation in excess of 50 percent is not warranted at any point during the period on appeal. (Continued on the next page) ? Accordingly, the benefit of the doubt doctrine is therefore not for application as to this claim. 38 U.S.C. §5107(b), Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021), affirmed en banc Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). R. Bisignani Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Loy, T., Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.