POSTTRAUMATIC STRESS DISORDER (PTSD)

MICHAEL MARTIN · 2026 · Case ID: A26029270

MIXED

Summary

The Veteran, who served in an unspecified branch of the U.S. military, appeals the denial of an initial compensable rating for headaches secondary to PTSD and TBI, and the Board remanded the claim for TDIU prior to October 21, 2024. The Board granted an initial disability rating of 70 percent for PTSD with anxiety and depression and TBI, finding that the Veteran's symptoms, including impaired memory, panic attacks, hypervigilance, emotional detachment, and irritability, met the criteria for this rating. The Board applied the benefit of the doubt doctrine, stating the evidence was in approximate balance, to grant the 70 percent rating for PTSD. However, the claim for headaches as secondary to PTSD and TBI was denied. The Board found that while the Veteran experienced frequent headaches, they did not meet the criteria for characteristic prostrating attacks averaging one in two months, as required for a compensable rating. The Board noted that the Veteran's symptoms, such as occasional passive suicidal ideation and irritability, did not rise to the level of a 70 percent rating for PTSD, distinguishing the case from precedent where such symptoms warranted the higher rating. The TDIU claim was remanded due to a pre-decisional duty-to-assist error, as the RO had not obtained a complete employment history for the entire appeal period.

Rationale

Symptoms span 30, 50, and 70 percent criteria; Evidence in approximate balance; Benefit of the doubt applied

Special Benefit

TDIU

Diagnostic Code

9411

Docket No.

201231-130612

Full Decision Text

Citation Nr: A26029270
Decision Date: 03/31/26 Archive Date: 03/31/26

DOCKET NO. 201231-130612
DATE: March 31, 2026

ORDER

Entitlement to an initial disability rating of 70 percent, but no greater, for posttraumatic stress disorder (PTD) with anxiety and depression and traumatic brain injury (TBI) is granted.

Entitlement to an initial compensable rating for headaches as secondary to the service-connected disability of posttraumatic stress disorder (PTSD) with anxiety and depression and traumatic brain injury (TBI) is denied.

REMANDED

Entitlement to a total disability rating due to individual unemployability (TDIU) prior to October 21, 2024, is remanded.

FINDINGS OF FACT

1. The Veteran's PTSD more nearly approximates occupational and social impairment, with deficiencies in most areas.

2. During the appeal period, the Veteran experienced headaches with less frequent attacks. The headaches did not manifest in characteristic prostrating attacks averaging one in 2 months over the last several months.

CONCLUSIONS OF LAW

1. The criteria for an initial rating of 70 percent for service-connected PTSD and TBI have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, 4.126, 4.130, Diagnostic Code 9411.

2. The criteria for an initial compensable rating for headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The rating decision on appeal was issued in July 2020 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the December 21, 2020, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on August 15, 2024. Therefore, the Board may only consider the evidence of record at the time of the July 2020 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 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.

However, because the Board is remanding the claim of entitlement to TDIU, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claim. 38 C.F.R. § 3.103(c)(2)(ii).

The record reflects that the Veteran's service-connected disabilities may have prevented her from working during the appeal period. See August 2024 Board hearing. Because a TDIU rating is inherent in any claim for an increased rating, see Rice v. Shinseki, 22 Vet. App. 447 (2009), it has been added as an issue.

Increased Ratings

Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; see generally 38 C.F.R. § Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran
22 Vet. App. 447 (2009), it has been added as an issue.

Increased Ratings

The Veteran's entire history is to be considered when making disability determinations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of the assignment of different ratings for distinct periods of time, based on the facts found, is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). However, in such cases, when the factual findings show distinct time periods during which the veteran exhibits symptoms of the disability at issue, and such symptoms warrant different disability ratings, staged ratings may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007).

1. Entitlement to an initial disability rating of 50 percent, but no greater, for posttraumatic stress disorder (PTD) with anxiety and depression and traumatic brain injury (TBI) is granted.

Preliminarily, with regards to whether separate ratings are warranted for the Veteran's TBI and psychiatric disabilities, where a veteran experiences residuals of a TBI along with a comorbid condition, such as a psychiatric condition, whether separate ratings are warranted for the TBI and comorbid condition depends on whether the symptoms of each are separable. See Diagnostic Code 8045, Note 1; 38 C.F.R. § 4.14. Where the manifestations of each are clearly separable, i.e. there are no overlapping symptoms, separate ratings will be warranted. However, where the manifestations are not clearly separable, separate ratings will not be warranted. See id.

During the period on appeal, the Veteran's service-connected psychiatric disability is rated 30 percent disabling under Diagnostic Codes 8045-9411. 38 C.F.R. § 4.130.

Diagnostic Codes 9201 through 9440 are rated using the General Rating Formula for Mental Disorders (General Formula). Under the General Formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation) due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events). Id.

A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per 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 in establishing and maintaining effective work and social relationships. Id.

A 70 percent rating is assigned 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. Id.

A 100 percent rating is assigned for 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
, 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. Id.

The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, all ratings in the general rating formula are associated with objectively observable symptomatology, and in Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." The Federal Circuit further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. Thus, "[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Id. at 118.

VA must engage in a holistic analysis that assesses the severity, frequency, and duration of the signs and symptoms of the psychiatric disability; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the time of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation on social impairment alone. Id.

The Board notes that the Veteran's PTSD with TBI disability was increased to 50 percent on October 21, 2024, based on an October 2024 VA examination report. This is after the current period on appeal.

Factual Background

In a March 2014 VA progress note, the Veteran reported PTSD symptoms, and depression/lack of interest in doing things. Veteran reported she has 'dissociated' ever since coming back from combat area. Reported not getting mad (except when kids are demanding), and again not caring about anything. Veteran stated she works at this VA in the file room and has worked as police dispatcher. Veteran denied suicidal ideations (SI) or homicidal ideations (HI). Upon mental status evaluation, the Veteran was alert and oriented with normal speech, and affect congruent with mood, depressed, anxious. Her thought process and association were normal. She had good/fair insight and good judgement. Memory was noted as impaired recent and remote.

In an early May 2014 VA mental health note, the Veteran reported she is having panic attacks, "smoking way too many cigarettes, and having trouble concentrating on anything else but my kids." Upon mental status evaluation, the examiner noted the Veteran was alert and oriented. She was appropriately groomed and cooperative. She was cooperative and her speech was of normal rate, pattern, and flow. She presented with an anxious mood and her affect was congruent. She did not show any evidence of psychotic thought processes and there was no evidence of significant cognitive dysfunctions. The Veteran denied any active SI/HI at that time.

During a June 2014 VA follow-up, the Veteran reported obsessively thinking about her situation, and this interferes with her job and doing other tasks. Veteran reported increase in anxiety and depressive symptoms. Veteran reports she feels anger and extreme frustration over the Child Protective Services (CPS) involvement in her home and with her family. Upon mental status evaluation, she was casually dressed with good grooming and hygiene.
ed and cooperative. She was cooperative and her speech was of normal rate, pattern, and flow. She presented with an anxious mood and her affect was congruent. She did not show any evidence of psychotic thought processes and there was no evidence of significant cognitive dysfunctions. The Veteran denied any active SI/HI at that time.

During a June 2014 VA follow-up, the Veteran reported obsessively thinking about her situation, and this interferes with her job and doing other tasks. Veteran reported increase in anxiety and depressive symptoms. Veteran reports she feels anger and extreme frustration over the Child Protective Services (CPS) involvement in her home and with her family. Upon mental status evaluation, she was casually dressed with good grooming and hygiene. Mood is depressed/anxious with congruent affect. She denied SI/HI. Judgment and insight were fair. Speech was clear, concise, and goal directed. Her cognitive memory appeared intact.

In an August 2014 note, the examiner noted Veteran was alert and oriented. She was cooperative and her speech was rapid with a flight of ideas. She presented with a manic mood and her affect was congruent. She did not show any evidence of psychotic thought processes and there was no evidence of significant cognitive dysfunctions.

During a September 2014 VA mental health evaluation, the Veteran denied suicidal and homicidal ideations. She repeatedly said she was stressed and was not suicidal or homicidal, just overwhelmed and panicked. Upon mental status evaluation, the Veteran was appropriately groomed and was cooperative. She was depressed, anxious mood was reported, and their affect was congruent. Veteran maintained good eye contact and would occasionally smile. Speech was normal in rate, pattern and flow. Hallucinations and delusions were denied, and the Veteran did not evidence any psychotic thought processes. There was no evidence of significant cognitive dysfunction. Veteran calmed down at end of this session.

In an October 2014 stressor statement, the Veteran reported she feels desensitized and uncaring. She also reported that to this day she is on guard without thinking.

The Veteran was afforded a PTSD VA examination in December 2014. The examiner noted that it is not possible to differentiate the symptoms associated with each of the Veteran's mental disorders or with the Veteran's TBI. There is some overlap among symptoms of PTSD, depression, and TBI. Moreover, the subjective memory problems that she reports can be from TBI or from marijuana dependence. She reports that her PTSD makes her very vigilant of her surroundings. This does not affect her work but makes her want to stay at home. Despite this, she is able to do things like grocery shopping and attending her kids' baseball games. The impairment at work seems to come from her adjustment disorder with anxiety and depression. She feels she gets anxiety attacks 2-3 times a week (more if she does not smoke pot). She was working in a file room with two other people. One day, one of her co-workers was talking about his wife's rape, and the Veteran "burst into tears and had a panic attack". She then asked her doctors for some time off from work. The TBI did not appear to cause any occupational or social impairment. The Veteran's symptoms included depressed mood, anxiety, panic attacks more than once a week, and mild memory loss. The Veteran was "fine right now" with anxious affect, clear speech, and organized thoughts. She reported a terrible memory, but her cognition was intact. There was no evidence or report of current/recurrent suicidal ideation, homicidal ideation, or psychosis. She reported that sometimes she has trouble sleeping and other times she feels fine. She also reported occasional passive thoughts of death, but no recent suicidal ideation.

The Veteran underwent a VA TBI examination in December 2014. He was diagnosed with TBI. The Veteran reported his symptoms of headaches and memory problems. Based upon the Veteran's subjective indications, the impact of facets 1 through 10 were:

1. A complaint 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), attention, concentration, or executive functions, but without objective evidence on testing;

2. Normal judgment;

3. Social interaction is occasionally inappropriate, noted as related to anxiety rather than TBI;

4. Always oriented to person, time, place, and situation;

5. Motor activity normal;

6. Visual spatial orientation: normal;

7. Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships, noted as anxiety but that it is due to a separate anxiety disorder rather than TBI;

8. One or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. She reports dysphoria and anxiety when she is not using marijuana. The examiner noted that these symptoms do not
, or executive functions, but without objective evidence on testing;

2. Normal judgment;

3. Social interaction is occasionally inappropriate, noted as related to anxiety rather than TBI;

4. Always oriented to person, time, place, and situation;

5. Motor activity normal;

6. Visual spatial orientation: normal;

9. Able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language; and

10. Normal consciousness

The examiner reported that the Veteran had subjective symptoms of headaches and depression/anxiety/unspecified trauma related disorder attributable to a TBI. There were no other pertinent findings, and her residual conditions do not impact her ability to work.

In a March 2015 VA mental health note, the Veteran reported doing somewhat better. She denied SI/HI and was alert and oriented. She was groomed and appropriately dressed. The Veteran was cooperative and her speech was of normal rate, pattern, and flow. She presented with an anxious and mildly depressed mood and her affect was congruent. The Veteran did not show any evidence of psychotic thought processes and there was no evidence of significant cognitive dysfunctions.

The Veteran testified before a Decision Review Officer in December 2015. She reported she had to go to the ER because she thought she was having a heart attack, and they said it was a panic attack. She stated she had never had one and did not know.

In March 2016 a private mental status examination was received from a licensed psychologist, J.A., M.A. Dr. A. provided diagnoses of chronic PTSD, major depressive disorder, panic disorder, and mild neurocognitive disorder due to TBI. The Veteran reported she worked for 2 years for CPS in Virginia and as a clerk in West Virgina for 3 years. She states she continues to work about 30 hours per week. She denied any interpersonal problems and stated she left CPS due to emotional problems working with abuse victims.

Dr. A. noted that the Veteran experienced unwanted memories of traumatic events, physical reactions when reminded of traumatic events, strong negative attitudes and distrust of others, diminished interest in pleasure in usual activities, severe feelings of detachment or alienation from others, moderate to severe changes in behavior to include irritable behavior and verbal and physical abuse of others, severe hypervigilance, problems with concentration and focus, moderate to severe sleep disturbance, marked impairment in social functioning, and mild impact on occupational functioning. The examiner noted that in terms of significant distress or impairment in social and occupational functioning, distress was noted as present but still manageable. As to global severity of the Veteran's PTSD symptoms, this was rated as moderate. It was noted she has definite distress or functional impairment, but functions satisfactorily with effort. The examiner found that the Veteran's PTSD is manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Upon mental status evaluation, the examiner noted the Veteran was oriented and her attitude was tentative, concertation was fair to poor, attention span was short, psychomotor activity was increased, speech patterns tended to be coherent but hesitant, ability abstract was somewhat impaired, affect was within normal limits, mood was anxious, energy level was low, memory was somewhat spotty and inexact, associations were a little loose. She denied mood swings, mania, hallucinations, and nightmares.

The Veteran was afforded a Board hearing in December 2019. Regarding her claim for PTSD, the Veteran testified that she experiences anxiety all the time to include anxiety and panic attacks, and that she experiences emotional numbness which further causes anxiety. The Veteran reported that she received some treatment at VA but stopped when she accepted employment at VA and became uncomfortable because she had to work with her counselor. The Veteran testified that she only leaves home to go across the street to her job and that she avoids crowds.

In a June 2020 VA progress note, the Veteran was reestablishing care within mental health. She stated she continues to deal with anxiety and panic attacks. The Veteran indicated that she was able to stay home for a couple of years with her children. She indicates this was a very positive experience. The Veteran reported she came back to work due to financial necessity. She indicated that her relationship with her husband has improved and shows fine growth. The Veteran believed that her job is a good fit as it is not overly stressful. There still has been some learning curve and challenges. She feels that she is navigating these successfully. The Veteran was presently not taking any psychotropic medication and denied any active SI/HI. Upon mental status evaluation, the Veteran was alert and oriented. She was pleasant and cooperative. Her speech was within normal parameters. She presented with a euthymic mood and her affect was congruent. She endorsed intermittent panic attacks with some regularity. She denied any psychotic thought processes. There was no evidence of significant cognitive dysfunction. The Veteran reported some difficulty with short-term memory. She stated she believes that she is much calmer and less reactive since her last sessions several years ago. At that time, she was not having anxiety attacks and generally sleep is fairly normal and restorative. She was well groomed and appropriately dressed.

In a subsequent June 2020 VA progress note, the Veteran reported an increase in her anxiety. She stated she has had triggering episodes with intrusive thoughts. She has not fully understood why these problems occur but is very aware of the negative impact they have had on her.

In a January 2021 VA progress note, the Veteran reported ongoing work issues and that she wished she could be at home full time with her children. She stated she is also providing support to her mother. She denied SI/HI and was alert and oriented. Upon mental status evaluation, the Veteran was groomed and dressed appropriately. She was pleasant and cooperative and her speech was within normal parameters. There was no psychomotor agitation. She presented with an anxious mood and her affect was congruent. The Veteran did not show any evidence of psychotic thought processes and there was no evidence of significant cognitive dysfunctions.

During an August 2024 Board hearing, the Veteran testified that she was having panic attacks and she went to the ER. She got FMLA at work because she was having them so often, like 2 to 4 times a week. She would have to go out to her car to cry and she felt like she could not breathe. It was happening almost daily, so she quit her job. She stated she had to quit her last couple of jobs just because her mental health could not take it. She stated that since she has been home, she does not have as many panic attacks, and it is mostly just detachment. She is either in a state of anxiety with panic attacks or completely detached, lying on the couch for days. She stated that during this time, she will shower two or three days a week. She reported difficulty with memory loss and leaving the house. She reported a low tolerance for people acting silly or stupid. She snaps at her kids, then has anxiety over it. She used to punch things or throw things. Especially whoever she was mad at, at home, even if it was one of the kids. It would be something as simple as a pillow, or an occasional shoe. She stated she had suicidal intent in 2005, and she continues to have suicidal thoughts today.

Analysis

After conducting a holistic analysis of the relevant evidence of record, the Board finds that a rating of 70 percent, but not higher is warranted for the Veteran's PTSD disability for the entire appeal period. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017).

The Board recognizes that the December 2024 VA examiner and March 2016 private examiner concluded that her disability resulted in occupational and social impairment with occasional deficiencies in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation, as contemplated by a 30 percent rating under Diagnostic Code 9411.

However, the evidence shows symptoms beyond the depressed mood, anxiety, chronic sleep impairment, and mild memory loss (such as forgetting names, directions, or recent events).

The evidence also supports impaired recent and remote memory (which is akin to impairment of short- and long-term memory); panic attacks more than once per week; severe hypervigilance (which is akin to impaired judgment); isolating or "dissociating" (which is akin to disturbances of motivation and mood); and, strong negative attitudes and distrust of others (which is akin to difficulty in establishing and maintaining
, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation, as contemplated by a 30 percent rating under Diagnostic Code 9411.

However, the evidence shows symptoms beyond the depressed mood, anxiety, chronic sleep impairment, and mild memory loss (such as forgetting names, directions, or recent events).

The evidence also supports impaired recent and remote memory (which is akin to impairment of short- and long-term memory); panic attacks more than once per week; severe hypervigilance (which is akin to impaired judgment); isolating or "dissociating" (which is akin to disturbances of motivation and mood); and, strong negative attitudes and distrust of others (which is akin to difficulty in establishing and maintaining effective work and social relationships) which are all symptoms contemplated by a 70 percent rating under Diagnostic Code 9411

She reported irritability with periods of violence, a symptom that is contemplated under the 70 percent criteria for Diagnostic Code 9411. However, the only evidence of irritability with periods of violence was in the March 2016 private evaluation. The examiner went on to state that she has definite distress or functional impairment, but functions satisfactorily with effort. As such, any irritability with periods of violence the Veteran experienced was likely episodic and not indicative of her overall symptomatology during the appeal period.

Although the Veteran denied suicidal ideation during VA treatment from July 2005 to June 2020 and January 2021, during the August 2024 Board hearing, the Veteran asserted suicidal thoughts since her episode in 2005. Here, the Board finds that any occasionally impaired thinking in the form of occasional passive suicidal ideation with no intent or plan the Veteran has experienced has been isolated and the severity, frequency, and duration of such symptoms do not represent the entire overall disability picture, and those isolated period(s) of suicidal ideation do not rise to the level associated with a 70 percent rating, particularly when considered along with the other evidence of record. Furthermore, the record does not indicate that the Veteran is a danger of physically hurting herself or others, as the evidence does not support a finding of violent behavior. The facts of this case are distinguishable from Bankhead v. Shulkin, 29 Vet. App. 10 (2017), in which the Court held that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas, warranting the assignment of a 70 percent rating. See also 38 C.F.R. § 4.130. Under the unique facts of Bankhead, the claimant was noted to have had recurrent suicidal thoughts and behaviors of varying severity, frequency, and duration throughout the relevant appeal period. Bankhead, 29 Vet. App. at 19-23. Here, the one report of suicidal ideation with no intent or plan in August 2024 Board hearing equates to no more than a history of one episode of impaired abstract thinking during the appeal period. Standing alone, this evidence does not show suicidal ideation of sufficient frequency, duration, and severity as to more nearly approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, contemplated by a 70 percent rating.

The Board also finds the evidence does not demonstrate that the Veteran's symptoms more nearly approximate gross impairment in thought process or communication, grossly inappropriate behavior, persistent danger of hurting others, disorientation to time or place, memory loss for names of close relatives, own occupation, or own name warranting a total disability rating. See 38 C.F.R. § 4.130, Diagnostic Code 9411.

The Board considered whether a higher rating is warranted based on the Veteran's TBI symptomatology. Based on the available evidence, including the December 2014 VA TBI examination, the Board assigns a "1" level of impairment for the memory, attention, concentration, and executive functions facet; a "1" level of impairment for social interaction; and, a "0" level of impairment for every other applicable facet. Consequently, as the Veteran's TBI symptoms rate at most, as a "1" under the facets listed above, a 10 percent rating would be warranted under Diagnostic Code 8045.

The Board further finds that the Veteran's 70 percent rating for PTSD under Diagnostic Code 9411 contemplates the memory, social interaction, and subjective symptoms of TBI. Thus, they are excluded from consideration in the rating for TBI because they would be duplicative and result in impermissible pyramiding. Again, the Veteran has been assigned a separate rating for his migraines (with light sensitivity) that is addressed below. The Court has interpreted 38 U.S.C. § 1155 as implicitly containing the concept that the rating schedule may not be employed as a vehicle for compensating a claimant twice (or more) for the same symptomatology; such a result would overcompensate the claimant for the actual impairment of her earning capacity and would constitute pyramiding of disabilities, which is cautioned against in 38 C.F.R. § 4.14. Essentially, under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation or rating of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. For purposes of determining whether the Veteran is entitled to separate ratings for different problems or residuals of an injury such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of or overlapping with the symptomatology of the other two conditions. Esteban, 6 Vet. App. 259.

As explained above, the Board finds that the Veteran's symptoms span those contemplated across the 30, 50 and 70 percent criteria. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; "Put differently, if the positive and negative evidence is in approximate balance (which includes but is not limited to equipoise), the claimant receives the benefit of the doubt." Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) Viewing the symptoms in their totality and keeping in mind the legal standard of approximate balance, the Board finds that a rating of 70 percent is appropriate. The Board concludes that the evidence in this case is approximately balanced and an award of an initial rating in excess of 70 percent, but no higher, for the service-connected PTSD and TBI is warranted. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

2. Entitlement to an initial compensable rating for headaches as secondary to the service-connected disability of posttraumatic stress disorder (PTSD) with anxiety and depression and traumatic brain injury (TBI) is denied.

Migraine headaches are rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100, for migraine. Under Diagnostic Code 8100, a noncompensable rating is warranted for migraines with less frequent attacks. A 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 50 percent rating is the highest schedular rating under Diagnostic Code 8100.

The rating criteria of Diagnostic Code 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). This renders 38 C.F.R. §§ 4.7 and 4.21 inapplicable. Johnson, 30 Vet. App. at 252.

The phrase "characteristic prostrating attacks" is used in the criteria corresponding to 10 percent and 30 percent ratings under Diagnostic Code 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. Pursuant to Dorland's Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as "extreme exhaustion or powerlessness." Thus, the phrase "characteristic prostrating attacks" is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness.

The rating criteria for a 50 percent rating contain several undefined phrases. The descriptive phrase "
4.21 inapplicable. Johnson, 30 Vet. App. at 252.

The rating criteria for a 50 percent rating contain several undefined phrases. The descriptive phrase "very frequent" connotes a frequency at least greater than once a month, as is required by the rating criteria corresponding to a lesser 30 percent rating. Johnson, 30 Vet. App. at 253. The phrase "completely prostrating" generally means that the migraines attack must render the veteran entirely powerless. Id. The completely prostrating attacks must also be "prolonged," which is defined as "to lengthen in time: extend duration: draw out: continue, protract." Id. (internal citation omitted).

The 50 percent rating criteria requires that the very frequent completely prostrating and prolonged attacks be "productive of severe economic inadaptability." Productive can be read as having either the meaning of "producing" or "capable of producing," and, with regard to severe economic inadaptability, nothing in Diagnostic Code 8100 requires that the claimant be unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004).

The Board notes that the Veteran's headaches disability was increased to 50 percent on October 21, 2024, based on an October 2024 VA examination report. This is after the current period on appeal.

Factual Background

In a March 2014 VA progress note, the Veteran reported moderate headaches and that she has to lay down if she gets a headache.

In a subsequent March 2014 note, the Veteran stated her headaches have increased to almost daily. They are improved with daily NSAIDs but becoming more constant and problematic. She self-treats with NSAIDs and isolation, no light sensitivity was reported.

The Veteran underwent a VA headaches examination in December 2014. She reported headaches but does not know when they started. She actually attributed her headache to "anxiety and tension; when I'm anxious and stiff the headache comes on in the neck and back of the head, but when I tell myself to relax, the headache goes away". The Veteran reported treating them with over-the-counter analgesics. The headaches start at back of head and neck, when anxious, with sensitivity to light and sound. These headaches last a couple of hours or less. The Veteran did not have characteristic prostrating attacks of migraine/non-migraine headache pain. The Veteran reported she thinks the headaches are more related to anxiety and come about when she is anxious/tense. Once she forces herself to relax, the headaches go away. She describes that this mostly tends to happen while driving, although it occasionally happens at work. When it occurs at work, it decreases her productivity somewhat.

In a March 2015 VA progress note, the Veteran reported headaches that are ongoing, almost daily. They rise in mid-morning and last most of the day. She described them as a dull achiness, frontal and top of head, with no specific throbbing or vision change or light sensitivity.

During a December 2015 DRO hearing, the Veteran reported that her headaches vary and that sometimes they are small and she can deal with it, and others she cannot. She stated that it never gets so bad that she cannot move. She doesn't get migraines, but there are days that are so bad she needs to take Asprin.

In a September 2017 VA progress note, the Veteran reported headaches 2 to 3 times per week.

In a December 2019 Board hearing, the Veteran's representative stated that while she does not have prostrating headaches, she does have them on a regular basis. She states he gets 3 to 4 headaches a week and that she takes Asprin or ibuprofen.

During an August 2024 Board hearing, the Veteran testified that she gets headaches every day. She stated that if she wakes up with the headache, she will have it all day. She stated she will take some Aspirin or Ibuprofen as soon as she wakes up. She also takes them sporadically throughout the day. The days she wakes up with a headache, she will not make any plans. She stated that she's never had migraine, but they sometimes hurt so badly they make her nauseous. If she takes medication on an empty stomach, she will end up throwing up. This happens a couple times a month. Even with her everyday headaches she will not have an appetite and will get a stomachache. She reported sensitive to light and sound and stated that she would lay in her room. With her everyday headaches, she needs to be left alone until the Ibuprofen kicks in. She has some vision loss and will feel like she is going to pass out, so she lays down. During her severe headaches, she cannot do household chores or drive. This happens one or two times a month.

Considering all relevant evidence of record, the Board finds the probative evidence persuasively supports a noncompensable rating for the Veteran's headache disability. During the period on appeal, the Veteran reports headaches almost every day, sometimes lasting up to four hours, that she treats with over-the-counter medications. The VA examiner found, with consideration of the Veteran's lay reports, that the Veteran did not have characteristic prostrating attacks of headache pain. Accordingly, the Board concludes that the Veteran's headaches occurred with less frequent attacks throughout the appeal period, corresponding to the criteria for a noncompensable rating under Diagnostic Code 8100.

A compensable rating under Diagnostic Code 8100 is not warranted unless there are headaches with characteristic prostrating attacks averaging one in 2 months over the last several months. Although the Veteran reported she "has to lay down" if she gets a headache and wait for her medication to kick in, she also reported it never gets so bad she cannot move. She stated during severe headaches she cannot do household chores or drive, but she has not endorsed "extreme exhaustion or powerlessness."

Thus, the Board concludes that the Veteran's headaches did not occur with characteristic prostrating attacks averaging one in 2 months over the last several months at any time during the appeal period. A compensable rating under DC 8100 is not warranted and the Veteran's claim for an initial compensable rating for headaches is denied.

In rating headaches or migraines under Diagnostic Code 8100, the Board may not consider the ameliorative effects of medication. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012); see also Ingram v. Collins, 38 Vet. App. 130, 131 (2025). The Board notes the Veteran's use of Asprin for headache pain but there is no evidence in the claims file that the Veteran was prescribed abortive or preventive medication for his headaches during the period on appeal.

With further regard to Jones and Ingram, although the December 2014 VA noted Veteran's report that she would use over the counter medications for headache pain, there was no indication that the examiner considered the ameliorative effects of medication in rendering the findings in the report nor did the Veteran indicate she was on any pain medications at the time of the examination. Instead, she merely noted she would take ibuprofen for pain if necessary. Here, the VA examiner considered the Veteran's lay description of her headaches in all worse-case scenarios. There is no indication that the examiner considered the ameliorative effects of medication and indeed, factored in the Veteran's description of when her headache pain is at its worst, i.e., discounted such effects. The Board, too, in rendering this decision, resolved all doubt in the Veteran's favor. As such, the Board concludes the VA examination of record is adequate to base a decision. See Jones, 26 Vet. App. at 63; see also Ingram, 38 Vet. App. at 131.

The Veteran reported that a headache happens almost every day sometimes caused by anxiety or tension, but that she has never had a migraine. See December 2014 VA examination report, August 2024 Board hearing transcript. The Veteran is competent to report readily observable symptoms, and the Board finds no reason to doubt her credibility. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.
Board, too, in rendering this decision, resolved all doubt in the Veteran's favor. As such, the Board concludes the VA examination of record is adequate to base a decision. See Jones, 26 Vet. App. at 63; see also Ingram, 38 Vet. App. at 131.

Thus, the evidence of record persuasively weighs against the claim for an initial compensable rating for headaches. Accordingly, the benefit of the doubt rule does not apply and entitlement to an initial compensable disability rating for headaches is denied. 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).

REASONS FOR REMAND

1. Entitlement to a total disability rating due to individual unemployability (TDIU) prior to October 21, 2024, is remanded.

The Veteran asserts TDIU is warranted during the period on appeal. A request for TDIU " is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim . . . or as part of a claim for increased compensation. Rice v. Shinseki 22 Vet. App. 447, 453-54 (2009). It is raised whenever a claimant seeks a higher disability evaluation and "presents cogent evidence of unemployability." Comer v. Peake, 553 F.3d 1362, 1367 (Fed. Cir. 2009)

The Veteran submitted a separate claim for TDIU in October 2024 and TDIU was granted in a May 2025 rating decision effective October 21, 2024. However, the claim of TDIU is raised as part of the increased rating claim in this appeal, therefore the entire appeal period must be considered. See, Payne v. Wilkie, 31 Vet. App. 373, 389 (2019); Harper v. Wilkie, 30 Vet. App. 356 (2018).

In a March 2016 private evaluation, the Veteran reported she worked for 2 years for CPS in Virginia and as a clerk in West Virgina for 3 years. She states she continues to work about 30 hours per week. She denied any interpersonal problems and stated she left CPS due to emotional problems working with abuse victims.

In a June 2020 VA progress note, the Veteran indicated that she was able to stay home for a couple of years with her children.

In this regard, the RO has not requested or obtained an employment history from the Veteran for the entire appellate period. The Board is unable to render a decision on whether the Veteran is entitled to a TDIU rating prior to the current October 2024 effective date. Accordingly, a remand is necessary to correct this pre-decisional duty-to-assist error.

The matters are REMANDED for the following action:

The Veteran should complete an updated Application for Increased Compensation Based on Unemployability (VA Form 21-8940) detailing a complete and accurate work history and income information, including self-employment and any other information regarding full-time or part-time employment or attempts to obtain employment prior to October 2024.

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In completing this application, the Veteran should include any and all education and/or training undertaken by the Veteran during this time period.

Martin T. Mitchell

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Boushehri, Diane M. Donahue

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.

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