Diagnostic Assessment — Cervicogenic Headache
Example 1 of 1 · fictitious patient (Veteran AH)
Diagnostic Assessment
Cervicogenic Headache
BOP Code: 28 of 2020 (Sprain and Strain)
RH Code: 27 of 2020 (Sprain and Strain)
ADF History
Veteran AH, date of birth 02 November 1978, Australian Army, Cavalry Crewman (light armoured vehicle crew commander), enlisted 15 January 1997, medically discharged 30 June 2016. Operational service: Iraq, 18 March 2006 to 02 November 2006 (warlike); Afghanistan, 21 February 2010 to 30 October 2010 (warlike).
Occupational History
As a cavalry crewman the veteran served as a driver, gunner and later crew commander of eight-wheeled light armoured vehicles. Crew commanders spend long shifts standing or seated in the turret with their head and shoulders exposed, wearing a combat helmet with night-vision equipment and a headset, which loads the upper cervical spine. Vehicles travel at speed over broken ground, culverts and irrigation channels, causing repeated whole-body jolting and sudden flexion-extension movements of the neck.
The trade also involves heavy manual handling: loading 25 mm and 7.62 mm ammunition, changing wheels weighing over 100 kilograms with team lifts, track and recovery work, and climbing on and off the vehicle hull at a height of about 2 metres. Falls from vehicles, collisions with hatches and turret fittings, and sustained awkward neck postures are recognised hazards of armoured vehicle crews.
History
Veteran AH, a cavalry crewman in the Australian Army, sustained a sprain of the upper cervical facet joints and a strain of the posterior neck muscles when his light armoured vehicle dropped into an irrigation channel at speed during warlike service in Iraq on 23 April 2006, and developed cervicogenic headache from that day. The headache worsened after a fall from his vehicle hull and heavy ammunition handling in Afghanistan in July 2010, and again after a turret injury on a field exercise in Australia in March 2013.
Timeline
- 10 Jan 2006 — Pre-deployment medical examination by the regimental medical officer recorded no neck pain, no headaches and a full, pain-free range of cervical movement. He was assessed as fit for deployment to Iraq. His prior medical record contained no history of neck injury or recurrent headache. "neck NAD, no headaches"
- 23 Apr 2006 — While crew commanding a light armoured vehicle on a security patrol in southern Iraq, the vehicle dropped into a concealed irrigation channel at about 40 km/h. Standing in the turret with his helmet and night-vision equipment, his head was thrown violently forward and then backward, and the right side of his helmet struck the hatch rim. Within an hour he had severe right-sided neck pain and stiffness, and by that evening a right occipital headache radiating to the right temple and eye. The combat medic recorded tenderness over the right upper cervical facet joints and spasm of the right trapezius and splenius capitis. "flexion-extension injury, R occipital headache"
- 25 Apr 2006 — A medical officer at the coalition base diagnosed an acute cervical sprain and strain with secondary headache. Cervical rotation to the right was limited to 40 degrees, with pain reproduced by pressure over the right C2-3 facet joint. Plain radiographs excluded fracture. He was prescribed paracetamol and ibuprofen and advised to rest for a week, but returned to turret duties after two days because no replacement crew commander was available. Physiotherapy was not available in the area of operations. "cervical sprain/strain, no physio"
- 14 Dec 2006 — After his return to Australia a garrison medical officer recorded persisting right-sided neck pain with headaches on about 6 days a month, beginning in the neck and spreading to the right forehead and eye, brought on by sustained turret postures and neck movement. Examination showed reduced right rotation and tenderness at C2-3. He was referred for physiotherapy. "cervicogenic headache 6 days/month"
- 14 Jul 2010 — During warlike service in Afghanistan the veteran fell about 2 metres from the hull of his vehicle while dismounting at night, landing on his right shoulder and the side of his helmeted head with his neck forced to the left. In the preceding three weeks he had loaded and unloaded ammunition cans of up to 25 kilograms for about two hours each day during resupply of his patrol base. The combat medic recorded an acute flare of right neck pain and headache. "fall from hull, neck flare"
- 02 Aug 2010 — Review by a medical officer recorded headaches on 20 days a month, more severe and lasting most of the day, with right rotation reduced to 25 degrees and muscle spasm extending into the right levator scapulae. He was placed on restricted duties for four weeks. Physiotherapy was again not available at his patrol base. "headaches 20 days/month, restricted"
- 12 Mar 2013 — On a field exercise in Queensland, his vehicle crossed a washout at speed and his head was thrown backwards against the rear of the turret hatch. He developed an acute exacerbation of right neck pain and daily headache. MRI showed increased right C2-3 facet joint oedema compared with 2010. "turret injury, daily headache"
- 18 Jun 2013 — A pain medicine specialist performed a right third occipital nerve block, which abolished the headache and neck pain for eight hours, confirming the right C2-3 facet joint as the source. Radiofrequency neurotomy was performed on 20 September 2013 with partial relief. He was medically downgraded from armoured vehicle duties and later discharged on 30 June 2016. "third occipital nerve block positive"
Symptoms
At onset the veteran had severe right-sided neck pain and stiffness within an hour of the injury and, by that evening, a right occipital headache spreading to the right temple and behind the right eye, made worse by turning his head and by the weight of his helmet. In the months after onset the headaches occurred on about 6 days a month and were consistently triggered by sustained neck postures.
After the 2010 and 2013 worsenings the headaches became near-daily, lasting most of the day, with nausea, light sensitivity on bad days and reduced right neck rotation. He now reports headaches on 15 to 20 days a month, always starting in the right upper neck, worse with reading, driving and computer use, and relieved only partly by heat, stretching and analgesia.
Imaging
- 25 Apr 2006 — X-ray cervical spine: "No fracture or subluxation. Straightening of the normal cervical lordosis consistent with muscle spasm."
- 30 Aug 2010 — MRI cervical spine: "Small right C2-3 facet joint effusion with mild periarticular oedema. No disc protrusion or neural compression."
- 20 Mar 2013 — MRI cervical spine: "Increased right C2-3 facet joint effusion and capsular oedema compared with 30 August 2010, with early degenerative change of the facet joint."
Onset Date
The most likely date of onset of this condition is 23 Apr 2006.
At that date the veteran was on warlike service in Iraq, crew commanding a light armoured vehicle on a security patrol. The vehicle dropped into a concealed irrigation channel at about 40 km/h and his head, weighted by a helmet and night-vision equipment, was thrown forward and backward, with the helmet striking the hatch rim. Neck pain began within an hour and a right occipital headache began that evening.
This date is appropriate because his pre-deployment medical examination of 10 January 2006 recorded no neck pain, no headaches and a full range of cervical movement, and the combat medic recorded the neck injury and headache on 23 April 2006, with medical officer diagnosis two days later. The pain and tenderness began within the 24 hours following the injury, as the Statement of Principles definitions of sprain and strain require.
For the onset factors, the sprain and strain factors require the significant physical force and the forceful stretching of the muscles to occur at the time of clinical onset. Both occurred at the moment the vehicle struck the channel on 23 Apr 2006: the whiplash movement drove force through the right C2-3 facet joint and its capsular ligaments and forcefully stretched the right trapezius and splenius capitis.
For the worsening factors, the first documented worsening was on 14 Jul 2010 in Afghanistan, when he fell 2 metres from the vehicle hull onto his head and shoulder, after three weeks of lifting ammunition cans of up to 25 kilograms for about two hours a day, from 23 Jun 2010 to 14 Jul 2010. Headache frequency rose from 6 to 20 days a month by 02 Aug 2010. The second documented worsening was on 12 Mar 2013 on a field exercise in Australia, when his head was thrown back against the turret hatch, with increased facet joint oedema on MRI on 20 Mar 2013 and daily headache.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Cervicogenic Headache (ICD-10-AM G44.8), secondary to a sprain of the right C2-3 facet joint and a strain of the right posterior neck muscles, assessed under the Statements of Principles concerning sprain and strain, Balance of Probabilities No. 28 of 2020 and Reasonable Hypothesis No. 27 of 2020.
Cervicogenic headache is pain referred to the head from a source in the cervical spine, most often the upper cervical facet joints (C1 to C3), their ligaments and capsules, the upper cervical discs and the posterior neck muscles. Pain signals from these structures converge with those from the head in the trigeminocervical nucleus of the upper spinal cord, so the brain perceives the pain in the back of the head, the forehead, the temple or around the eye. The headache is typically one-sided, begins in the neck, is provoked by neck movement or sustained awkward postures, and is accompanied by reduced neck movement. It commonly follows a whiplash or other trauma to the neck that sprains the facet joint ligaments and strains the neck muscles.
The condition began with a flexion-extension injury on warlike service in Iraq on 23 April 2006, worsened after a fall and heavy lifting in Afghanistan in July 2010 and after a turret injury in Australia in March 2013, and was confirmed by a diagnostic third occipital nerve block on 18 June 2013.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
23 April 2006.
When did the veteran first present to a health / medical provider for this condition?
23 April 2006.
When was the condition confirmed / formally diagnosed?
25 April 2006.
When did the veteran first present to you (or your practice) for this condition?
08 April 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically by a medical officer on 25 April 2006, who recorded an acute cervical sprain and strain with tenderness over the right C2-3 facet joint, spasm of the right trapezius and splenius capitis, reduced right rotation and a right occipital headache provoked by neck movement, with radiographs excluding fracture. The pain and tenderness began within 24 hours of the injury, meeting the Statement of Principles definitions of a sprain (stretching or tearing of joint ligaments) and a strain (stretching or tearing of muscle). The headache pattern meets the International Classification of Headache Disorders criteria for cervicogenic headache: it began in close temporal relation to the neck injury, is unilateral and provoked by neck movement, and is accompanied by reduced cervical range of motion.
The cervical source was confirmed by MRI on 30 August 2010 and 20 March 2013, which showed a right C2-3 facet joint effusion and capsular oedema, and by a right third occipital nerve block on 18 June 2013, which abolished the headache for eight hours. The worsening is documented by the rise in headache frequency from 6 to 20 days a month in August 2010, by daily headache after March 2013 and by the increased facet joint changes on repeat MRI.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 23 April 2006, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Iraq in 2006, where the injury occurred, and in Afghanistan in 2010, where the condition worsened. The Balance of Probabilities instrument applies to peacetime service, including the field exercise in Queensland on 12 March 2013 at which the condition worsened again. Cervicogenic headache does not have its own Statement of Principles; it is the clinical manifestation of the cervical sprain and strain, so the sprain and strain instruments are applied.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Sprain and Strain, No. 28 of 2020
Causative factors
Factor 9(1): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament; — MET
- On 23 April 2006, while performing his duties as a crew commander, the veteran's vehicle dropped into an irrigation channel at about 40 km/h and his head, loaded by a helmet and night-vision equipment, was thrown forward and backward with the helmet striking the hatch rim. This applied a significant physical force through the right C2-3 facet joint. Neck pain and facet joint tenderness began within an hour, meeting the definition of sprain, so the force was applied at the time of clinical onset. The injury arose out of his service as a member of the Defence Force.
Factor 9(2): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon; — MET
- The same flexion-extension movement on 23 April 2006 forcefully stretched the right upper trapezius and splenius capitis, and the medical officer recorded spasm and tenderness of those muscles within 48 hours, with pain beginning within the first hour. The forceful stretching occurred at the time of the clinical onset of the strain and arose out of his duties.
Worsening factors
Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament; — MET
- On 12 March 2013, on a peacetime field exercise in Queensland, the veteran's vehicle crossed a washout at speed and his head was thrown backwards against the rear of the turret hatch, applying a significant force through the already injured right C2-3 facet joint. He developed an acute exacerbation of neck pain and daily headache, and MRI on 20 March 2013 showed increased facet joint effusion and capsular oedema compared with 2010, confirming the clinical worsening at the time of the force.
Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon; — MET
- The hyperextension injury of 12 March 2013 forcefully stretched the right posterior neck muscles, and in the same exercise he was carrying out wheel changes and recovery tasks with team lifts of over 100 kilograms. Spasm of the right trapezius, splenius capitis and levator scapulae was recorded the next day, and the headache became daily, documenting a clinical worsening of the strain at that time.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain. — MET
- After the injury of 23 April 2006 the medical officer prescribed a week of rest, but the veteran was returned to turret duties after two days because no replacement crew commander was available, and physiotherapy was not available in the area of operations. On return to Australia the physiotherapy referral made on 14 December 2006 was not available until March 2007 because of waiting lists at the garrison health centre, and by then the headaches had become established on about 6 days a month. Under Brew v Repatriation Commission (1999), these service circumstances prevented appropriate clinical management and contributed to the persistence and worsening of the condition.
Reasonable Hypothesis — Statement of Principles concerning Sprain and Strain, No. 27 of 2020
Causative factors
Factor 9(1): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical onset of a sprain to that joint ligament; — MET
- On warlike service in Iraq on 23 April 2006 the veteran's light armoured vehicle dropped into a concealed irrigation channel at about 40 km/h during a security patrol, throwing his helmeted head forward and backward and striking the helmet against the hatch rim. This drove a significant physical force through the right C2-3 facet joint at the moment of injury, and pain and facet tenderness began within an hour. The sprain arose directly from his operational service.
Factor 9(2): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical onset of a strain to that muscle or tendon; — MET
- The whiplash movement on warlike service in Iraq on 23 April 2006 forcefully stretched the right trapezius and splenius capitis. The combat medic recorded spasm of these muscles the same day, and the medical officer diagnosed a cervical strain on 25 April 2006. The strain began at the moment of the operational injury.
Worsening factors
Factor 9(3): experiencing a significant physical force applied to or through the affected joint, at the time of the clinical worsening of a sprain to that joint ligament; — MET
- On warlike service in Afghanistan on 14 July 2010 the veteran fell about 2 metres from the hull of his vehicle while dismounting at night, landing on his right shoulder and the side of his helmeted head with his neck forced to the left. This applied a significant force through the right C2-3 facet joint. Headache frequency rose from 6 to 20 days a month by 02 August 2010, and MRI on 30 August 2010 showed a right C2-3 facet joint effusion, documenting the clinical worsening at the time of the fall.
Factor 9(4): forceful stretching or high intensity use of a muscle or tendon at the time of the clinical worsening of a strain to that muscle or tendon; — MET
- From 23 June 2010 to 14 July 2010, on warlike service in Afghanistan, the veteran loaded and unloaded ammunition cans of up to 25 kilograms for about two hours each day during patrol base resupply, lifting them overhead onto the vehicle. This high intensity use of the trapezius and levator scapulae culminated in the fall of 14 July 2010, which forcefully stretched the right neck muscles. Spasm extending into the right levator scapulae was recorded on 02 August 2010, when the strain had clinically worsened.
Factor 9(5): inability to obtain appropriate clinical management for sprain or strain. — MET
- On warlike service in Iraq in April 2006 the veteran was returned to turret duties two days after the injury, against the medical officer's advice to rest for a week, and no physiotherapy was available. On warlike service in Afghanistan in August 2010 physiotherapy was again unavailable at his patrol base, and he received only analgesia and four weeks of restricted duties. Under Brew v Repatriation Commission (1999), operational circumstances that prevent rest and recommended treatment are an inability to obtain appropriate clinical management, and the headaches became more frequent and persistent as a result.
The % contribution of the causes is 100% and significant.
Sequelae
The cervicogenic headache is the principal sequela of the accepted cervical sprain and strain. The persisting C2-3 facet joint injury has also led to early facet joint degeneration on MRI (cervical spondylosis), chronic neck pain with reduced rotation, and sleep disturbance from nocturnal headache, each of which may be claimed as a sequela of the accepted condition.
Unintended Consequence
Met in part. Regular ibuprofen and paracetamol were prescribed by Defence medical officers from April 2006 for the headaches, and by 2012 the veteran had developed medication-overuse headache superimposed on the cervicogenic headache, which increased headache frequency until a supervised withdrawal in 2013. This is an unintended consequence of treatment provided by the Commonwealth while he was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After the injury on warlike service in Iraq on 23 April 2006 the veteran was advised to rest for a week but was returned to turret duties after two days because no replacement crew commander was available, and physiotherapy was not available in the area of operations. After the 2010 worsening in Afghanistan physiotherapy was again unavailable. On return to Australia in 2006 the physiotherapy referral was delayed by about three months. During these periods the headaches became established and then more frequent. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the circumstances of his service prevented him from obtaining the rest and treatment that were clinically appropriate, and that inability contributed to the persistence and worsening of his cervicogenic headache.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 10 Jan 2006, Pre-deployment medical examination, Regimental Medical Officer
- 23 Apr 2006, Casualty treatment record, Combat medic, Iraq
- 25 Apr 2006, Medical officer consultation and cervical spine X-ray report, Medical Officer and Radiologist, Iraq
- 14 Dec 2006, Outpatient health record, Medical Officer, Garrison health centre
- 14 Jul 2010, Casualty treatment record, Combat medic, Afghanistan
- 02 Aug 2010, Medical officer consultation and duty restriction, Medical Officer, Afghanistan
- 30 Aug 2010, MRI cervical spine report, Radiologist
- 12 Mar 2013, Field exercise treatment record, Medical Officer
- 20 Mar 2013, MRI cervical spine report, Radiologist
- 18 Jun 2013, Third occipital nerve block report, Pain medicine specialist
- 20 Sep 2013, Radiofrequency neurotomy procedure report, Pain medicine specialist
- Statement of Principles concerning Sprain and Strain (Balance of Probabilities) No. 28 of 2020, Repatriation Medical Authority
- Statement of Principles concerning Sprain and Strain (Reasonable Hypothesis) No. 27 of 2020, Repatriation Medical Authority
