Diagnostic Assessment — Migraine
Example 1 of 1 · fictitious patient (Veteran D)
Diagnostic Assessment
Migraine
BOP Code: 8 of 2018 (Migraine)
RH Code: 7 of 2018 (Migraine)
ADF History
Veteran D, date of birth 14 June 1982, Australian Army, Infantry Soldier (Rifleman, later Section Commander), enlisted 03 February 2001, medically discharged 18 November 2019. Operational service: Iraq, 02 April 2006 to 21 November 2006 (warlike); Afghanistan, 09 February 2009 to 14 October 2009 (warlike); Middle East Area of Operations, 12 January 2015 to 30 August 2015 (warlike).
Occupational History
As an infantry soldier the veteran conducted dismounted patrols carrying 35 to 50 kilograms, stood long night pickets and worked irregular hours with frequent sleep deprivation. Field rations, limited water and long periods without toilet access during patrols commonly cause dehydration and constipation, and deployed troops in Iraq and the Middle East were exposed to smoke from open burn pits, diesel exhaust and fine desert dust.
Infantry duties also carry exposure to blast overpressure, weapons noise, glare and heat, all recognised triggers of headache, and in the deployed environment access to specialist medical care, regular medicines and follow-up is limited to what a regimental aid post or role 2 facility can provide.
History
Veteran D, an infantry soldier in the Australian Army, developed migraine with aura on 18 June 2009 during warlike service in Afghanistan, two weeks after starting glyceryl trinitrate ointment for an anal fissure, on a background of severe and persistent asthma that followed burn pit smoke exposure in Iraq. The migraine converted to chronic migraine with an admission for status migrainosus during his 2015 deployment to the Middle East, when glyceryl trinitrate was again prescribed, and he had by then been obese for more than five years.
Timeline
- 11 Jun 2007 — Seven months after returning from Iraq, where he had lived and worked beside an open burn pit at a forward operating base, the veteran was reviewed by a respiratory physician for daily wheeze, chest tightness and cough. Spirometry showed an FEV1 of 58 per cent of predicted with a significant bronchodilator response. He had night-time symptoms on four to five nights a week, two oral prednisolone courses for flare-ups since March, and was unable to complete his basic fitness assessment. "FEV1 58 per cent, nightly wheeze"
- 19 Feb 2008 — Respiratory review recorded that daily symptoms, nocturnal waking and frequent flare-ups had persisted continuously since March 2007, a period of eleven months, despite high-dose inhaled corticosteroid and long-acting beta-agonist therapy. A fourth prednisolone course had been needed in December 2007. The respiratory physician recorded severe persistent asthma, with partial control achieved only after a further three months of treatment. "severe persistent asthma, eleven months"
- 10 Jan 2009 — Pre-deployment health assessment for Afghanistan. The veteran denied headaches, visual disturbance or neurological symptoms, and neurological examination was normal. Weight 96 kg, height 1.79 m, BMI 30.0. Asthma was recorded as partly controlled on inhaled therapy, with a reliever needed three to four times a week. "nil headache, neuro exam normal"
- 04 Jun 2009 — During warlike service in Afghanistan the veteran presented to the regimental aid post with rectal bleeding and severe pain on defaecation after several weeks of constipation on long patrols with restricted water and ration-pack diet. Examination confirmed a posterior anal fissure. The medical officer prescribed glyceryl trinitrate 0.2 per cent ointment applied twice daily for eight weeks, as diltiazem cream was not held at the patrol base. "anal fissure, GTN 0.2% bd"
- 19 Jun 2009 — The veteran re-presented the morning after a first attack of zig-zag visual disturbance spreading across his left visual field for 25 minutes, followed by a severe throbbing right-sided headache with nausea, vomiting and light sensitivity that lasted 14 hours and left him unable to go on patrol. He had four similar attacks over the following five weeks while continuing glyceryl trinitrate. Neurological examination between attacks was normal. "visual aura then throbbing headache"
- 08 Dec 2009 — After return to Australia a neurologist reviewed a headache diary recording seven attacks since June 2009, each with typical visual aura followed by unilateral pulsating headache with nausea and photophobia lasting 6 to 24 hours. MRI brain was normal. He diagnosed migraine with aura and noted that the attacks began during glyceryl trinitrate treatment on deployment. Sumatriptan was prescribed for acute attacks. "migraine with aura confirmed"
- 03 Feb 2010 — Periodic health examination recorded a weight of 98 kg and BMI 30.6. His weight rose further to 104 kg (BMI 32.5) by 2012, attributed to reduced aerobic training while his asthma was poorly controlled and to repeated courses of oral corticosteroids. BMI remained at or above 30 at every subsequent annual review. "BMI 30.6, weight increasing"
- 29 Jun 2015 — During warlike service in the Middle East the veteran was treated for a recurrent anal fissure with glyceryl trinitrate 0.4 per cent ointment from 08 June 2015, after constipation on long vehicle-borne tasks. His headache diary showed migraine on 18 to 20 days a month since mid-June, up from two attacks a month, and on 27 June he was admitted to a role 2 facility with a migraine that had lasted more than 72 hours despite oral treatment. CT brain was normal. He was treated with intravenous fluids, metoclopramide and dexamethasone. "status migrainosus, CT brain normal"
- 22 Sep 2015 — Neurology review after return from the Middle East confirmed conversion from episodic to chronic migraine: headache on 22 days a month for three months, with migraine features on 14 days a month. BMI 33.1. Prophylaxis that had been interrupted on deployment because propranolol was contraindicated by his asthma and no alternative was stocked was replaced with topiramate, and he was referred for onabotulinumtoxinA. "chronic migraine, 22 days/month"
Symptoms
At onset the veteran had attacks of zig-zag visual disturbance lasting 20 to 30 minutes, followed by severe throbbing headache, usually on one side, with nausea, vomiting and marked sensitivity to light and noise. Attacks lasted 6 to 24 hours, forced him to lie in a dark room and stopped him from patrolling. Between attacks he was well.
From June 2015 the headaches became near-daily, with migraine features on more than half of those days, and he required hospital treatment for an attack lasting more than three days. He now reports headache on 12 to 16 days a month despite prophylaxis, with two to four disabling attacks a month, and he avoids bright light, screens and noisy environments.
Imaging
- 08 Dec 2009 — MRI brain: "Normal brain parenchyma. No structural lesion, white matter abnormality, vascular malformation or evidence of raised intracranial pressure."
- 27 Jun 2015 — CT brain (non-contrast): "No haemorrhage, infarct, mass lesion or hydrocephalus. Normal study."
- 05 Oct 2015 — MRI brain with MR venography: "Unchanged normal brain. Patent dural venous sinuses. No cause for the change in headache pattern identified."
Onset Date
The most likely date of onset of this condition is 18 Jun 2009.
At that date the veteran was on warlike service in Afghanistan with an infantry battle group, conducting daily dismounted patrols from a patrol base. He had been applying glyceryl trinitrate 0.2 per cent ointment twice daily since 04 June 2009 for an anal fissure, and on the evening of 18 June he had his first attack of visual aura followed by a severe one-sided throbbing headache with vomiting.
This date is appropriate because his pre-deployment health assessment of 10 January 2009 recorded no headaches and a normal neurological examination, and he presented to the regimental aid post with the first attack on the morning of 19 June 2009. The neurologist's history of 08 December 2009 dates the first of seven typical attacks to that night. The date falls within uninterrupted full-time service and within his warlike service in Afghanistan.
For the nitric oxide donor factor at onset, the treatment ran from 04 June 2009 to 30 July 2009, and the veteran was applying glyceryl trinitrate on 18 June 2009. For the asthma factor, the five years before onset run from 18 Jun 2004 to 18 Jun 2009; severe and persistent asthma, with daily symptoms, night-time symptoms on more than one night a week, frequent flare-ups and an FEV1 of 58 per cent of predicted, was present continuously from March 2007 to February 2008, a cumulative period of eleven months within that window.
For the worsening factors, the documented clinical worsening occurred on 27 Jun 2015, when the veteran was admitted with status migrainosus during warlike service in the Middle East, by which time his attacks had increased from two to 18 to 20 a month; conversion to chronic migraine was confirmed on 22 September 2015. He was applying glyceryl trinitrate 0.4 per cent ointment from 08 June 2015, so he was undergoing nitric oxide donor treatment at the worsening. The five years before the worsening run from 27 Jun 2010 to 27 Jun 2015; his BMI was 30.6 in February 2010 and at or above 30 at every review through 2015, so he was obese throughout that period. The same five-year window contains a second period of severe and persistent asthma, from August 2012 to May 2013.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Migraine with aura (ICD-10 G43.1), which later transformed into chronic migraine, under the Statements of Principles concerning migraine, Balance of Probabilities No. 8 of 2018 and Reasonable Hypothesis No. 7 of 2018.
Migraine is a primary headache disorder in which recurrent attacks of moderate to severe headache, typically one-sided and pulsating, last 4 to 72 hours and are accompanied by nausea, vomiting or sensitivity to light and sound, and are aggravated by routine physical activity. In migraine with aura, the headache is preceded by fully reversible visual, sensory or speech symptoms that develop gradually over 5 to 60 minutes. Nitric oxide is a key signalling molecule in the migraine cascade, and nitric oxide donors such as glyceryl trinitrate are well known to provoke migraine attacks in susceptible people. Chronic migraine is diagnosed when headache occurs on at least 15 days a month for more than three months, with migraine features on at least eight of those days.
The diagnosis began on 18 June 2009 during warlike service in Afghanistan while the veteran was being treated with glyceryl trinitrate, was confirmed by a neurologist on 08 December 2009 after seven typical attacks, and worsened to chronic migraine with status migrainosus in June 2015.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
18 June 2009.
When did the veteran first present to a health / medical provider for this condition?
19 June 2009.
When was the condition confirmed / formally diagnosed?
08 December 2009.
When did the veteran first present to you (or your practice) for this condition?
17 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 by a consultant neurologist on 08 December 2009 on the basis of a headache diary recording seven attacks since June 2009, each with a typical visual aura developing over several minutes and lasting less than an hour, followed by a unilateral pulsating headache of severe intensity with nausea, vomiting and photophobia lasting 6 to 24 hours. This meets the International Classification of Headache Disorders criteria for migraine with aura, and therefore the Statement of Principles definition of migraine. Neurological examination was normal between attacks and MRI brain excluded a structural cause.
The worsening was established by the headache diary from June 2015, which showed attacks on 18 to 20 days a month, an admission on 27 June 2015 for a migraine lasting more than 72 hours (status migrainosus) with a normal CT brain, and neurology review on 22 September 2015 confirming chronic migraine with headache on 22 days a month and migraine features on 14 days. This meets limbs (a), (c) and (d) of the definition of clinical worsening of migraine. A normal MRI and MR venogram on 05 October 2015 excluded a secondary cause for the change.
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 18 June 2009, after 1 July 2004, during continuous full-time service that included warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Iraq in 2006, where the burn pit exposure that led to his asthma occurred, in Afghanistan in 2009, where the migraine began during glyceryl trinitrate treatment, and in the Middle East in 2015, where the migraine worsened.
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 Migraine, No. 8 of 2018
Causative factors
Factor 9(1): undergoing treatment with a nitric oxide donor, at the time of the clinical onset of migraine; — MET
- On 04 June 2009 an ADF medical officer prescribed glyceryl trinitrate 0.2 per cent ointment, applied twice daily, for an anal fissure caused by constipation from restricted water intake, ration-pack diet and long patrols without toilet access. Glyceryl trinitrate is a nitric oxide donor named in the Statement of Principles. The veteran was applying it on 18 June 2009, the date of onset, and it was continued to 30 July 2009. The treatment was prescribed and supplied by Defence health services during his continuous full-time service, and the fissure for which it was given arose from the conditions of that service.
Worsening factors
Factor 9(2): undergoing treatment with a nitric oxide donor, at the time of the clinical worsening of migraine; — MET
- A recurrent anal fissure, again caused by constipation and dehydration on long vehicle tasks, was treated by an ADF medical officer with glyceryl trinitrate 0.4 per cent ointment twice daily from 08 June 2015. The veteran was applying it when his migraine frequency rose from two to 18 to 20 attacks a month and when he was admitted with status migrainosus on 27 June 2015. The treatment was prescribed by Defence health services in the course of his service.
Factor 9(3): being obese for at least the five years before the clinical worsening of migraine; — MET
- The veteran's BMI was 30.6 on 03 February 2010, 32.5 in 2012 and 33.1 on 22 September 2015, and it was recorded at or above 30 at every annual health examination in between. He was therefore obese throughout the five years before the worsening, from 27 June 2010 to 27 June 2015. His weight gain followed loss of aerobic fitness from asthma that developed after his service, repeated courses of oral prednisolone prescribed for that asthma, and the sedentary periods of light duties that followed flare-ups.
Factor 9(4): inability to obtain appropriate clinical management for migraine. — MET
- During his deployment to the Middle East from January to August 2015 the veteran's preventive treatment could not be maintained: propranolol was contraindicated by his asthma, and the alternative prophylactic agents recommended by his neurologist were not held at the deployed health facility. Triptan supply ran out in May 2015 and was not replaced for five weeks, and the glyceryl trinitrate that was provoking his attacks could not be substituted because diltiazem cream was not available. No neurology review was possible until September 2015. The migraine worsened to chronic migraine with status migrainosus during this period. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Migraine, No. 7 of 2018
Causative factors
Factor 9(1): undergoing treatment with a nitric oxide donor, at the time of the clinical onset of migraine; — MET
- The veteran began glyceryl trinitrate 0.2 per cent ointment on 04 June 2009 while on warlike service in Afghanistan, for an anal fissure caused by the dehydration, ration-pack diet and prolonged patrolling of that deployment. He was applying it on 18 June 2009 when he had his first attack of migraine with aura at the patrol base. Diltiazem, which would have avoided nitric oxide donor exposure, was not available in the operational area.
Factor 9(2): having severe and persistent asthma within the five years before the clinical onset of migraine; — MET
- The veteran developed asthma after warlike service in Iraq from April to November 2006, during which he lived and worked beside an open burn pit at a forward operating base. From March 2007 to February 2008, a continuous period of eleven months within one year, he had daily wheeze and chest tightness, night-time symptoms on four to five nights a week, four flare-ups requiring oral prednisolone and an FEV1 of 58 per cent of predicted on 11 June 2007. This meets limbs (a) to (e) of the definition of severe and persistent asthma, and it fell within the five years before onset, from 18 June 2004 to 18 June 2009.
Worsening factors
Factor 9(3): undergoing treatment with a nitric oxide donor, at the time of the clinical worsening of migraine; — MET
- On warlike service in the Middle East the veteran was prescribed glyceryl trinitrate 0.4 per cent ointment from 08 June 2015 for a recurrent anal fissure caused by the conditions of that deployment. He was using it when his attacks rose to 18 to 20 a month and when he was admitted to a role 2 facility with status migrainosus on 27 June 2015.
Factor 9(4): having severe and persistent asthma within the five years before the clinical worsening of migraine; — MET
- The veteran's burn pit-related asthma flared again from August 2012 to May 2013 after a prolonged respiratory infection, with daily symptoms, night waking on most nights, three oral prednisolone courses and an FEV1 of 59 per cent of predicted on 14 November 2012, a cumulative period of ten months within one year. This fell within the five years before the worsening, from 27 June 2010 to 27 June 2015. The asthma arose from his warlike service in Iraq in 2006.
Factor 9(5): being obese for at least the five years before the clinical worsening of migraine; — MET
- The veteran's BMI was 30.6 in February 2010 and remained at or above 30, reaching 33.1 by September 2015, throughout the five years before the worsening, from 27 June 2010 to 27 June 2015. The weight gain followed the loss of fitness and repeated corticosteroid courses caused by asthma arising from burn pit exposure on warlike service in Iraq, and he remained obese during his warlike service in the Middle East, where the worsening occurred.
Factor 9(6): inability to obtain appropriate clinical management for migraine. — MET
- On warlike service in the Middle East from January to August 2015 the veteran had no access to suitable migraine prophylaxis, his triptan supply lapsed for five weeks, the provoking glyceryl trinitrate could not be replaced because diltiazem was not stocked, and neurology review was not possible. The migraine converted to chronic migraine with status migrainosus during that deployment.
The % contribution of the causes is 100% and significant.
Sequelae
The migraine is a sequela of the veteran's accepted anal fissure, through the glyceryl trinitrate prescribed to treat it, and of his accepted asthma, which arose from burn pit exposure in Iraq. The obesity that contributed to the worsening was itself a sequela of the asthma and of the corticosteroids used to treat it. The chronic migraine has in turn caused medication-overuse headache from frequent analgesic and triptan use, recorded in 2016, and contributed to the sleep disturbance and low mood documented from 2016.
Unintended Consequence
Met. The onset and the worsening of the migraine are each an unintended consequence of glyceryl trinitrate ointment, prescribed by ADF medical officers and paid for by the Commonwealth on warlike service in 2009 and 2015 (section 6A of the DRCA and the equivalent provisions of the MRCA). Glyceryl trinitrate is a recognised trigger of migraine, and headache is a listed adverse effect in its product information.
Inability to Attain Appropriate Medical Management
MET. During his deployment to the Middle East from January to August 2015 the veteran could not obtain suitable migraine prophylaxis, his acute treatment lapsed for five weeks, the glyceryl trinitrate provoking his attacks could not be substituted, and no specialist neurology review was available. The migraine worsened from two attacks a month to chronic migraine, with an admission for status migrainosus on 27 June 2015. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the operational limits on medicines and specialist care amounted to an inability to obtain appropriate clinical management. The continuation of glyceryl trinitrate for eight weeks in 2009, after the first attacks, because no alternative was held at the patrol base, is a further instance of the same barrier.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 11 Jun 2007, Respiratory medicine consultation and spirometry, Respiratory physician
- 19 Feb 2008, Respiratory medicine review, Respiratory physician
- 10 Jan 2009, Pre-deployment health assessment, Medical Officer, Garrison health centre
- 04 Jun 2009, Regimental aid post record, Medical Officer, Afghanistan
- 19 Jun 2009, Regimental aid post record, Medical Officer, Afghanistan
- 08 Dec 2009, Neurology consultation and MRI brain report, Neurologist and Radiologist
- 03 Feb 2010, Periodic health examination, Medical Officer, Garrison health centre
- 14 Nov 2012, Respiratory medicine review and spirometry, Respiratory physician
- 27 Jun 2015, Role 2 admission record and CT brain report, Middle East Area of Operations
- 29 Jun 2015, Deployed health centre record, Medical Officer, Middle East Area of Operations
- 22 Sep 2015, Neurology review, Neurologist
- 05 Oct 2015, MRI brain and MR venography report, Radiologist
- Statement of Principles concerning Migraine (Balance of Probabilities) No. 8 of 2018, Repatriation Medical Authority
- Statement of Principles concerning Migraine (Reasonable Hypothesis) No. 7 of 2018, Repatriation Medical Authority
