TINNITUS

MARIAH N. SIM · 2026 · Case ID: A26040875

MIXED

Summary

The veteran, who served in the Marine Corps and Army between December 2002 and December 2009, including deployments, appeals a March 2025 rating decision. The Board granted service connection for tinnitus, finding the evidence supported the claim despite inconsistent statements from the veteran regarding onset and affected ear, resolving reasonable doubt in his favor. The Board also granted service connection for erectile dysfunction secondary to service-connected PTSD, relying on a VA examiner's opinion that, while negative for toxic exposure, positively linked the condition to PTSD. The veteran's claim for a compensable rating for migraine headaches was denied, as the evidence did not meet the criteria for characteristic prostrating attacks, and the Board found further development regarding medication effects would be speculative. The case was remanded for further development regarding hypertension, as the initial VA opinion was inadequate, failing to adequately address toxic exposures and the link between sleep apnea and hypertension. The Board found the veteran's tinnitus complaints during service and subsequent National Guard service, coupled with his PTSD and memory loss, supported granting service connection for tinnitus.

Rationale

Veteran has current diagnosis of tinnitus.; In-service and post-service records document recurring complaints and treatment.; Inconsistencies in reported onset/affected ear not due to bad character or malingering.; Benefit of the doubt resolved in veteran's favor.

Service Branch

MARINE CORPS

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250331-529113

Full Decision Text

Citation Nr: A26040875
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 250331-529113
DATE: April 30, 2026

ORDER

Entitlement to service connection for tinnitus is granted.

Entitlement to service connection for erectile dysfunction as secondary to service-connected posttraumatic stress disorder (PTSD) is granted.

Entitlement to a compensable rating for service-connected migraine headaches is denied.

REMANDED

Entitlement to service connection for hypertension is remanded.

FINDINGS OF FACT

1. Resolving reasonable doubt in favor of the Veteran, his tinnitus began during active service or is otherwise related to his high probability of in-service noise exposure.

2. Resolving reasonable doubt in favor of the Veteran, his erectile dysfunction is secondary to his service-connected PTSD.

3. At no point during the appeal period did the Veteran's service-connected migraine headaches involve symptoms approximating characteristic prostrating attacks or completely prostrating and prolonged attacks productive of severe economic inadaptability of any frequency.

CONCLUSIONS OF LAW

1. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.309.

2. The criteria for entitlement to service connection for erectile dysfunction as secondary to service-connected PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

3. The criteria for entitlement to a compensable rating for service-connected migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.97, Diagnostic Code 8100.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Marine Corps from December 2002 to December 2006 and in the United States Army from December 2008 to December 2009.

This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2025 rating decision issued by the Veteran of Veterans Affairs (VA) Regional Office (RO). Later in March 2025, the Veteran submitted VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), appealing the March 2025 rating decision to the Board. He elected the Direct review option; therefore, the Board may only consider the evidence of record at the time of the March 2025 rating decision. 38 C.F.R. § 20.301.

As to any evidence associated with the claims file after the March 2025 rating decision, to include evidence submitted by the Veteran, the Board cannot consider such. 38 C.F.R. § 20.301; see also Cook v. McDonough, 36 Vet. App. 175 (2023). To the extent this evidence may relate to the issues remanded below, such evidence will be considered by the RO in adjudication of such. 38 C.F.R. § 3.103(c)(2)(ii). To the extent this evidence may relate to the issues decided below, the Veteran is advised to submit a Supplemental Claim. Instructions for doing so are attached to this decision.

As an initial matter, the Board notes that, prior to initiation of the instant appeal, the Veteran did not appoint a Veterans Service Organization (VSO) or private representative to represent him. When the Board docketed this appeal in April 2025, he was informed that he had 90 days from the date his appeal was received to change his representation. See April 2025 BVA Docketing Letter. In September 2025, he appointed National Association of County Veterans Service Officers (NACVSO) to represent him. See September 2025 VA Form 21-22. Under 38 C.F.R. § 20.1304(b), the Board will not accept a request for a change in representation after the 90-day period has expired except when an appellant demonstrates on motion, in writing, that there was good cause for the delay. Here, there has been no such motion. Therefore, the Board finds that good cause has not been shown, and the Appellant remains unrepresented for the purpose of this appeal. The most recent request for a change in representation to NACVSO will be honored for any pending matters at the RO.

1. Entitlement to service connection for tinnitus is granted.

The Veteran seeks service connection for tinnitus. Initially, the Board recognizes the RO's favorable finding that
. Under 38 C.F.R. § 20.1304(b), the Board will not accept a request for a change in representation after the 90-day period has expired except when an appellant demonstrates on motion, in writing, that there was good cause for the delay. Here, there has been no such motion. Therefore, the Board finds that good cause has not been shown, and the Appellant remains unrepresented for the purpose of this appeal. The most recent request for a change in representation to NACVSO will be honored for any pending matters at the RO.

1. Entitlement to service connection for tinnitus is granted.

The Veteran seeks service connection for tinnitus. Initially, the Board recognizes the RO's favorable finding that the Veteran had a high probability of in-service noise exposure in his military occupational specialty (MOS) as an infantryman. See March 2025 Rating Decision.

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires competent evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service; and (3) a causal relationship or nexus between the current disability and any injury or disease during service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009).

Service connection may also be established for "chronic diseases" as listed in 38 C.F.R. § 3.309 (a) where evidence shows a diagnosis manifest to a compensable degree within the presumptive period after service, or a continuity of symptomatology since service. See 38 C.F.R. §§ 3.303 (b), 3.307; Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). Because tinnitus is considered a "chronic disease" as an "other organic disease[] of the nervous system" under 38 C.F.R. § 3.309(a), the Board looks to whether service connection is warranted on a presumptive or direct basis. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a).

The Veteran's service treatment records include multiple notations as to hearing abnormalities and/or tinnitus during his first period of active service. In December 2004, he was placed on a hearing conservation program "due to routine exposure to hazardous noise." See December 2004 Chronological Record of Medical Care. In January 2005, an audiologist, after conducting testing, advised him that his results indicated an early warning for a decrease in hearing. See January 2005 Hearing Conservation Data. In February 2006, shortly following his return from a deployment, he denied experiencing ringing in his ears; however, at a July 2006 reassessment, he endorsed ringing in his ears. See February 2006 Post-Deployment Health Assessment; July 2006 Post-Deployment Health Reassessment. In November 2006, upon his separation from his first period of active service, he reported feeling as if his hearing had gotten worse, and a provider documented tinnitus as to his right ear. In reviewing his medical history, he marked that he then-currently or previously had a history of hearing loss and ear, nose, or throat (ENT) trouble, and he elaborated on such as "[d]uring an IED[,] I lost hearing through my right ear." See November 2006 Report of Medical Assessment & Report of Medical History. Later in November 2006, an audiologist, after conducting testing, noted that he exhibited a positive significant threshold shift in his hearing acuity. See November 2006 Hearing Conservation Data.

During his second period of active service, following his return from deployment, the Veteran denied any hearing trouble or ringing in his ears in both November 2009 and March 2010. See November 2009 Post-Deployment Health Assessment; March 2010 Post-Deployment Health Reassessment.

The Board notes that, after his first period of active service, both prior to and following his second period of active service, the Veteran served in the California National Guard until June 2014. See National Guard Report of Separation and Record of Service. Upon establishing care with VA in January 2012, while still a member of the California National Guard, he reported a history of bilateral tinnitus, but in February 2012, he was referred to an ENT specialist for unilateral tinnitus and reported intermittent right ear tinnitus. See January 2012 Internal Medicine H&P Note; February 2012 Audiology Consult. In
. See November 2009 Post-Deployment Health Assessment; March 2010 Post-Deployment Health Reassessment.

The Board notes that, after his first period of active service, both prior to and following his second period of active service, the Veteran served in the California National Guard until June 2014. See National Guard Report of Separation and Record of Service. Upon establishing care with VA in January 2012, while still a member of the California National Guard, he reported a history of bilateral tinnitus, but in February 2012, he was referred to an ENT specialist for unilateral tinnitus and reported intermittent right ear tinnitus. See January 2012 Internal Medicine H&P Note; February 2012 Audiology Consult. In March 2012, he reported left ear tinnitus. See March 2012 Otolaryngology Consult.

Post-service, in May 2019, the Veteran reported occasional tinnitus. See May 2019 Internal Medicine H&P Note. In October 2019, he reported a history of intermittent left ear tinnitus since he was 23 years old, which he indicated had become more distracting over time. See October 2019 Audiology Consult. In December 2019, an ENT specialist noted that he was referred for unilateral tinnitus, but he reported experiencing bilateral tinnitus for the last two years, which was louder in the right ear and had disappeared for the two weeks prior. See December 2019 ENT Consult. In March 2020, he reported that his tinnitus was less frequent and not as bothersome. See March 2020 Otolaryngology Outpatient Note.

In sum, the Veteran's in-service and post-service treatment records document that he exhibited a significant threshold shift as to his hearing and complained of tinnitus during both his first period of active service and overall National Guard service, but he reported a varied nature and history of tinnitus in seeking treatment thereafter. The Board notes, however, that his service-connected PTSD and/or TBI have been manifested by, in part, decreased memory since at least 2019, and as of 2025, he reported experiencing memory loss such that he had to keep a list of his coworkers' names and roles. See November 2019 VA PTSD Examination; February 2020 VA TBI Examination; March 2025 VA PTSD Examination. The Board further notes that, despite recurringly complaining of and seeking treatment for tinnitus between 2006 and 2020, he did not seek VA compensation for tinnitus until February 2025. See February 2025 VA Form 21-526EZ. The Board thus finds that, given the Veteran's circumstances and recurring complaints of tinnitus for treatment purposes, and resolving reasonable doubt in his favor, his credibility is not reduced by his inconsistency in his statements as to the onset and history of his tinnitus. In assessing the credibility and weight given to evidence, the Board may consider factors such as internal inconsistency, facial plausibility, consistency with other evidence submitted, bad character, bias, self-interest, malingering, and desire for monetary gain. See Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996).

The Veteran was afforded a VA examination and opinions to assess the nature and etiology of his tinnitus in March 2025. At the examination, he reported that, right after getting out of the service in 2014, he started experiencing left ear tinnitus, but he did not realize it was abnormal or a medical concern until someone notified him about it in 2017. He further reported that his tinnitus worsened in 2022 such that he felt he needed to be seen by a doctor for it.

Per the associated opinion as to direct service connection, the March 2025 VA examiner noted review of the claims file and opined that the Veteran's was not at least as likely as not caused by or a result of military noise exposure. The examiner described the Veteran's June 2002, December 2002, December 2003, January 2005, and November 2006 in-service audiograms as revealing normal hearing bilaterally and summarized his 2012, 2019, 2020, and 2024 treatment records as to tinnitus. The examiner stated that there was conflicting information about his tinnitus, noting that he previously reported bilateral versus left-sided versus right-sided tinnitus beginning around 2006, 2014, or 2017. (As an aside, the examiner described the conflicting information as contained in his service treatment records (STRs), but in listing specific "STRS" notes as to tinnitus, only listed notes from his VA treatment records. The examiner concluded
2002, December 2002, December 2003, January 2005, and November 2006 in-service audiograms as revealing normal hearing bilaterally and summarized his 2012, 2019, 2020, and 2024 treatment records as to tinnitus. The examiner stated that there was conflicting information about his tinnitus, noting that he previously reported bilateral versus left-sided versus right-sided tinnitus beginning around 2006, 2014, or 2017. (As an aside, the examiner described the conflicting information as contained in his service treatment records (STRs), but in listing specific "STRS" notes as to tinnitus, only listed notes from his VA treatment records. The examiner concluded that, because the Veteran's description of the side affected by his tinnitus and reported onset date of such are not consistent with information in his "STRS" (but again, seemingly only referring to his VA treatment records), his tinnitus is likely non-organic in nature.

Per the associated opinion as to the Veteran's participation in toxic exposure risk activities (TERAs), the March 2025 VA examiner again noted review of the claims file and marked that the Veteran's tinnitus was less likely than not caused by his various recognized TERAs after considering his total potential exposure through all applicable military deployment and the synergistic, combined effect of all of his TERAs. The examiner reiterated much of the above-detailed rationale provided as to her direct service connection opinion and stated that "it is not possible to determine whether the tinnitus is at least as likely as not caused by military service and/or exposure to toxins while in military service." The examiner again reasoned that, given the scope and degree of inconsistencies as to the Veteran's affected ear and onset date, his tinnitus is non-organic in nature. The examiner concluded that, as a result, a determination of etiology could not be made based on current information.

The Board finds both March 2025 VA opinions inadequate and consequently not probative. Significantly, despite repeatedly referring to the Veteran's "STRS" in the rationale for her opinions, the examiner did not address highly relevant notations in the Veteran's service treatment records, including his in-service complaints of tinnitus and an audiologist's notation that he underwent a significant threshold shift during his first period of active service. Further, the examiner premised both opinions on her determination that his tinnitus was non-organic in nature, but the examiner did not explain what she meant by this categorization and did not either (1) opine as to the etiology of his, as determined by her to be, non-organic tinnitus, or (2) explain why a categorization of tinnitus as non-organic indicates, in and of itself, that it is not related to in-service acoustic trauma or any toxic exposure.

After review of the lay and medical evidence, the Board finds that service connection is warranted. Significantly, a layperson is capable of observing tinnitus. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). Here, the Veteran complained of tinnitus during his first period of active service in 2006, again complained of tinnitus during his National Guard service, generally, in 2012, and recurringly complained of and sought treatment for tinnitus thereafter. Although he has been inconsistent in his described nature and onset of his tinnitus in seeking treatment for such, the Board recognizes that his service-connected PTSD and/or TBI are specifically manifested by memory loss, and there is simply no indication that his inconsistencies in describing the history of his tinnitus are due to bad character, bias, self-interest, malingering, or desire for monetary gain. Caluza, 7 Vet. App. at 511-512.

In sum, the Veteran has a current diagnosis of tinnitus. Moreover, there is no sufficient basis for the Board to further develop the claim. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose).

Accordingly, the Board finds that the evidence is for the claim and entitlement to service connection for tinnitus is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

2. Entitlement to service connection for erectile dysfunction as secondary to service-connected PTSD is granted.

The Veteran seeks service connection for erectile dysfunction, but he did
additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose).

2. Entitlement to service connection for erectile dysfunction as secondary to service-connected PTSD is granted.

The Veteran seeks service connection for erectile dysfunction, but he did not specify how he felt this disability was related to his service or any service-connected disability in filing his initial claim as to such. See February 2025 VA Form 21-526EZ.

Service connection may be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310.

The Board finds that a discussion of direct service connection is unnecessary as service connection for erectile dysfunction is warranted on a secondary basis, as discussed below.

The Veteran was afforded a VA examination and TERA opinion to assess the nature and etiology of his claimed erectile dysfunction in March 2025. Per the examination report, an examiner documented that he was diagnosed with erectile dysfunction in 2020. Per the TERA opinion, the examiner opined that his erectile dysfunction was less likely than not caused by his various recognized TERAs after considering his total potential exposure through all applicable military deployment and the synergistic, combined effect of all of his TERAs. In making this opinion, the examiner did not provide rationale as to the possible impact of the Veteran's TERAs; instead, the examiner summarized medical literature as to an increased rate of sexual dysfunction in veterans with PTSD; PTSD being commonly associated with overall sexual function, sexual desire, sexual satisfaction, and sexual distress; and PTSD affecting sexual arousal, orgasm function, erectile dysfunction, premature ejaculation, sexual pain, and frequency of sexual activity. The examiner noted that the Veteran reported that, despite his libido being intact, he could not mentally form an erection without use of Viagra, and so the examiner concluded that his erectile dysfunction is secondary to his service-connected PTSD.

The Board notes that, although the January 2025 VA opinion represents a negative nexus opinion as to the impact of the Veteran's TERAs on his erectile dysfunction, and although the examiner did not complete the section of the opinion from as to secondary service connection, the substance of the opinion represents a positive nexus opinion as to the impact of his service-connected PTSD on his erectile dysfunction. The Board finds the rationale for the January 2025 VA opinion probative as to secondary service connection, as the examiner reviewed the claims file prior to preparing such and applied the Veteran's circumstances to medical principles therein.

In sum, the Veteran has a current diagnosis of erectile dysfunction. The only probative opinions of record are in support of the Veteran's claim for entitlement to service connection. Moreover, there is no sufficient basis for the Board to reject this supportive opinion and to further develop the claim. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose).

Accordingly, the Board finds that the evidence is for the claim and entitlement to service connection for erectile dysfunction as secondary to service-connected PTSD, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

3. Entitlement to a compensable rating for service-connected migraine headaches is denied.

The Veteran seeks a compensable rating for his service-connected migraine headaches, which are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8100.

3. Entitlement to a compensable rating for service-connected migraine headaches is denied.

The Veteran seeks a compensable rating for his service-connected migraine headaches, which are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8100.

The Board notes that the period on appeal as to the service-migraine headaches rating begins on December 17, 2024-the date of receipt of the Veteran's notification of his intent to file a claim for benefits, which he timely followed with, in part, a formal increased rating claim as to his service-connected migraine headaches, which was, in turn, adjudicated in the March 2025 rating decision on appeal. See December 2024 Intent to File Letter; February 2025 VA Form 21-526EZ. The Veteran has not continuously pursued an increased rating as to his migraine headaches since his award of service connection for such in May 2020, and so the period on appeal does not precede the date of receipt of notification of his intent to file a claim for benefits and does not reach to the date of service connection for this disability (i.e., December 19, 2019). While the Veteran's increased rating claim is before the Board on appellate review, there is a defined evidentiary record. Here is the evidence of record at the time of the March 25, 2025 rating decision.

Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10.

Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011).

Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994).

Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991).

Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id.

In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, 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 conditions is duplicative or
Id.

The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10.

The veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a).

Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claim.

When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

Under Diagnostic Code 8100, a 0 percent rating is warranted for less frequent attacks; a 10 percent rating is warranted for characteristic prostrating attacks averaging one in 2 months over the last several months; a 30 percent rating is warranted for characteristic prostrating attacks occurring on average once a month over the last several months; and a 50 percent rating, the highest schedular rating, is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. In rating headaches or migraines, the Board may not consider the ameliorative effects of medication. See Jones v. Shinseki, 26 Vet. App. 56, 63 (1992).

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." In Johnson, the Court defined prostrating as "lacking in vitality or will: powerless to rise: laid low," citing to WEBSTER'S THIRD NEW INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE UNABRIDGED 1822 (1966). Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). The Court further explained that "[b]ecause DC 8100 specifically governs migraine headaches, the phrase 'characteristic prostrating attacks' plainly describes migraine attacks that typically produce powerlessness or a lack of vitality." Id. at 252.

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

The Veteran was afforded a VA examination assessing the nature and severity of his migraine headaches in March 2025. At the examination, he reported continuing to experience headaches without significant improvement or worsening over time, and he indicated that he treated such with ibuprofen as needed. The examiner marked that he experienced pulsating or throbbing head pain on both sides of his head typically lasting for less than one day with nausea, sensitivity to light and sound, and changes in vision. The examiner further marked that he did not experience characteristic prostrating attacks of migraine or non-migraine headache or completely prostrating and prolonged attacks of migraine or non-migraine pain. As to functional impact, the examiner marked that his migraine headaches did not impact his ability to perform any type of occupational task.

The Veteran's VA treatment records are associated with the claims file; however, these records contain no complaints or treatment for headaches from shortly prior to or during the appeal period. Instead, he specifically denied experiencing headaches in November 2024. See November 2024 Physician Emergency Department Note. The claims file does not contain any lay statements submitted or received during the appeal period that relate to the nature and/or severity of the Veteran's migraine headaches.

Further review of the record shows that the Veteran receives VA treatment providers for various disabilities, to include his headaches. However, there is no indication from the treatment notes of record that the Veteran has reported headache symptoms that are worse than those noted above.

After review of the lay and medical evidence, the Board finds that a compensable rating is not warranted. Significantly, there is simply insufficient evidence of record to suggest that the Veteran experienced any more than less frequent attacks of migraine headaches during the appeal period. He has not reported experiencing headache attacks that typically produce powerlessness or a lack of vitality so as to represent characteristic prostrating attacks contemplated by the 10 or 30 percent rating criteria, and at no point shortly prior to or during the appeal period did an examiner or provider document that he experienced headaches of a variety, severity, and frequency so as to approximate characteristic prostrating attacks or completely prostrating and prolonged attacks productive of severe economic inadaptability at any frequency.

In making the above finding, the Board has considered the Veteran's report of nausea, sensitivity to light and sound, and visual changes as to his headaches during the appeal period. Diagnostic Code 8100 contemplates this symptom. See Holmes v. Wilkie, 33 Vet. App. 67, 72-73.

Additionally, the Board recognizes that the March 2025 VA examiner documented that the Veteran treated his migraine headaches with ibuprofen. The Court has held that in assigning a disability rating, VA may not consider the ameliorative effects of medication where such effects are not explicitly contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56 (2012). More recently, the Court stated that the "the Board [is] obligated to discount the beneficial effects of the medication taken for each disability and evaluate the baseline severity of those disabilities" and held that "Jones applies in the evaluation of musculoskeletal disabilities where the relevant [diagnostic code] does not reference medication as a factor in evaluation." Ingram v. Collins, 38 Vet. App. 130, 139 (2025). The Court did not specifically discuss the application of Jones to the evaluation of migraine headaches, but the Board has nonetheless considered such.

The Board notes that neither Jones nor Ingram address how the Board is to discount the beneficial effects of medication, to include when used as treatment for headache and migraine symptoms and where examiners do not reasonably have the ability to assess symptomatology both with and without use of medication. Remanding this appeal to order an addendum medical opinion based on Jones and Ingram, and in the lens of the rating criteria under 38 C.F.R. § 4.124a, would almost certainly require an examiner to engage in medical speculation and would result in a medical opinion that lacks the degree of certainty to ascertain, even under the benefit-of-the-doubt standard, the impact of the ameliorative effects of medication on the severity of a veteran's headaches or migraines, particularly in terms of prostration considered in assessing the severity of these disabilities. See, e.g., Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2005) (medical opinions that are speculative have "little probative value"). Significantly, one of the judges in McCarroll, joined by another judge in concurrence, expressed the same concern as to the implications of the holding in Jones:

The requirement that the Secretary "may not consider the relief afforded by [a veteran's] medication when" applying the rating schedule, as Jones demands...invites medical speculation in trying to guess what a veteran's symptoms might be without the medication, or medical malpractice in the cessation of medication so that the veteran's symptoms without medication might be recorded. The former invites non-helpful guesswork by medical practitioners,...and the latter raises, at a minimum, serious ethical concerns that no court should encourage. That Jones essentially requires the Board to consider whether a medical examination is required to determine how serious a veteran's symptoms would have been in an alternate reality in which he or she was not taking his or her required medication should alone demonstrate the fallacy of the Jones holding.

McCarroll v. McDonald, 28 Vet. App. 267, 278 (2016) (internal citations omitted). Because it is highly unlikely that remand to obtain a retrospective medical opinion as to the ameliorative effects of medication on the severity of the Veteran's migraine headaches during the appeal period would result in a probative, non-speculative opinion as to such, the Board does not wish to further delay adjudication of the Veteran's appeal to engage in likely unfruitful further development pursuant to Jones and Ingram.

Further, the Board notes that VA compensation does not contemplate hypothetical symptoms or impairment. Instead, the purpose of VA benefits is to compensate for decreased earning capacity - to compensate for actual symptoms or impairment that an individual experiences in the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If medications are taken regularly and effectively, that is, on an ordinary day the Veteran takes medications that improve functioning, then § 4.10 specifically requires VA to rate his disability based on his actual functioning. The Veteran's manifestations of pain and associated symptoms during the appeal period have been considered in ascertaining whether his migraine headaches approximated higher rating criteria, but it still remains the Board's obligation to rate the condition based on the application of the rating criteria found in the diagnostic codes to the objective medical evidence.

While the Board does not doubt the Veteran's sincere belief that his service-connected migraine headaches warrant a higher initial and recognizes that he is certainly competent to report the onset, frequency, and ongoing existence of certain symptoms, to include head pain, nausea, and sensitivity to light and sound (as he so reported at the March 2025 VA examination), he has not reported such symptoms of the frequency and severity so as to resemble characteristic prostrating attacks, and the March 2025VA examiner, a trained medical professional, competently and persuasively determined that his reported disability picture did not represent characteristic prostrating attacks.

The Board has considered whether staged ratings under Hart v. Mansfield, supra is appropriate; however, the Board finds that his symptomatology was been stable throughout the period on appeal. Therefore, assigning staged ratings is not warranted. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017).
reported such symptoms of the frequency and severity so as to resemble characteristic prostrating attacks, and the March 2025VA examiner, a trained medical professional, competently and persuasively determined that his reported disability picture did not represent characteristic prostrating attacks.

Additionally, the Board has considered whether an inferred claim for a TDIU has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran's current employment status is unknown. The Veteran has also not alleged, and the record does not suggest, that he is unable to obtain and maintain employment due solely to his service connected migraine headaches. As such, a Rice claim is not raised.

In so finding the above, the Board acknowledges the Veteran's contentions that his migraine headache disorder is more severe than contemplated by the current rating assigned. The Veteran is competent to report symptoms such as pain because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). However, he is not considered competent to medically attribute or assess the severity of his right thumb disorder as required in the Diagnostic Code. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, his statements do not constitute competent evidence and, the Board assigns more probative weight to the competent medical evidence of record.

The evidence is not in approximate balance but is persuasively against the claim; therefore, there is no reasonable doubt to be resolved in favor of the Veteran. Entitlement to a compensable rating for service-connected migraine headaches is denied.

REASONS FOR REMAND

1. Entitlement to service connection for hypertension is remanded.

The Board must remand appeals to the RO to correct pre-decisional duty to assist errors. See 38 C.F.R. § 20.802(a). Here, the Board's review of the record reveals duty to assist errors as to his claimed hypertension, as discussed in more detail below.

Initially, the Board notes that a veteran is presumed to have been sound upon entry into service when no preexisting condition is noted at entry. See 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Upon the Veteran's entrance to active service, in June 2002, he exhibited a blood pressure of 139/85, but an examiner assessed his heart and vascular system as normal. The examiner specifically assigned a "1" rating as to his capacity and stamina under the PULHES profile system, indicating a high level of fitness as to his capacity and stamina. See June 2002 Report of Medical Examination; see Odiorne v. Principi, 3 Vet. App. 456, 457 (1992) (observing that the "P" in "PULHES" profile reflects the overall physical and psychiatric condition of the veteran's capacity and stamina and is assessed on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service)). Consequently, despite exhibiting a blood pressure of 139/85 upon entrance to service, the presumption of soundness attaches to his cardiovascular system, to include as to hypertension.

The Veteran was afforded a VA examination as to the nature of his hypertension in March 2025. At the examination, he reported that, in 2013, his blood pressure was high but he still passed a physical examination. He further reported that, for a while, he was very depressed and "they" linked his high blood pressure to his PTSD. The examiner diagnosed him with hypertension and noted that, although she could not find records meeting the VA criteria of two blood pressure readings on the same day for three different days, there was sufficient documentation of elevated blood pressures and continued treatment for hypertension over the years.

Per an associated TERA opinion rendered by the March 2025 VA examiner, the examiner opined that the Veteran
to hypertension.

Per an associated TERA opinion rendered by the March 2025 VA examiner, the examiner opined that the Veteran's hypertension was less likely than not caused by his indicated TERAs, after considering his total potential exposure through all applicable military deployments and the synergistic, combined effect of all of his TERAs. The examiner reasoned that, upon his entrance to service, he had a body mass index of 29.4, which was 0.6 less than being considered obese, and his blood pressure was 139/85, which is considered stage 1 hypertension. The examiner concluded, without further rationale, that since he came into service with high blood pressure, it is less likely than not that his blood pressure was caused by his TERAs. The examiner did not discuss whether any of his presumed or conceded TERAs are, through medical principles or medical literatures, known to be associated with hypertension.

The Board finds that, despite the March 2025 VA examiner's rationale for her negative nexus opinion almost entirely resting on the Veteran's blood pressure being at 139/85 upon his entrance to service, this single heightened blood pressure reading, considered alongside the fact that his entrance examiner assessed his heart and vascular system as normal, does not rise to the level of clear and unmistakable evidence of his hypertension preexisting his service. As specifically noted by the March 2025 VA examiner in the remarks section of her report, for VA purposes, hypertension is defined as "diastolic blood pressure is predominantly 90mm. or greater" and isolated systolic hypertension is defined as "systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm." See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1).

Based on the above, the Board further finds that the March 2025 VA TERA opinion is inadequate since, rather than discussing the possible impact of the Veteran's various TERAs on his hypertension, the examiner solely focused on his weight and entrance blood pressure reading in the rationale for her opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion obtains probative weight from "factually accurate, fully articulated, sound reasoning for the conclusion"). A mere conclusory statement, even if it comes from a medical professional, is not sufficient. The RO's failure to obtain an adequate opinion as to the impact of the Veteran's presumed and conceded TERAs on his claimed hypertension constitutes a pre-decisional error requiring remand.

Separately, the Board finds that the evidence of record prior to issuance of the decision on appeal triggered the low threshold to obtain an opinion as to the impact of the Veteran's obstructive sleep apnea on his hypertension. In this regard, in both February 2024 and June 2024, a VA provider noted that hypertension is a health consequence of obstructive sleep apnea, and the Veteran has been service-connected for obstructive sleep apnea since October 2019. See November 2024 & June 2024 Pulmonary Notes. As such, prior to issuance of the decision on appeal, there was competent evidence suggestive of a possible association between his service-connected obstructive sleep apnea and hypertension, and so the RO's failure to obtain an opinion addressing this theory of entitlement also constitutes a pre-decisional error requiring remand.

The matter is REMANDED for the following action:

Obtain an addendum medical opinion as to the Veteran's claimed hypertension. After complete review of the claims file, the examiner must respond to the following:

As to participation in toxic exposure risk activities,

(a.) Is the Veteran's hypertension at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) due to his presumed in-service exposure to fine particulate matter and burn pits and other toxins; possible exposure to the chemicals, toxins, and diseases listed in his ILER; any other exposures conceded or presumed by the RO; and/or the synergistic, combined effect of all of his toxic exposure risk activities?

The Board notes that the Veteran's full list of presumed and conceded exposures should be contained in his ILER and the
addendum medical opinion as to the Veteran's claimed hypertension. After complete review of the claims file, the examiner must respond to the following:

As to participation in toxic exposure risk activities,

The Board notes that the Veteran's full list of presumed and conceded exposures should be contained in his ILER and the VA TERA Memoranda.

As to secondary service connection,

(b.) Is the Veteran's hypertension at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) proximately due to or aggravated by his service-connected obstructive sleep apnea?

The Board notes that, in February 2024 and June 2024, a provider advised the Veteran that hypertension is a health consequence of obstructive sleep apnea. See February 2024 & June 2024 Pulmonary Notes.

The examiner must address each exposure and theory. The opinions must be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested.

Mariah N. Sim

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board A. Tierno

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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