Diagnostic Assessment — Tension-type Headache
Example 1 of 1 · fictitious patient (Veteran M)
Diagnostic Assessment
Tension-type Headache
BOP Code: 38 of 2018 (Tension-Type Headache)
RH Code: 37 of 2018 (Tension-Type Headache)
ADF History
Veteran M, date of birth 14 June 1985, Australian Army, Infantry Soldier (Rifleman, later Section Commander), enlisted 03 February 2004, medically discharged 18 November 2020. Operational service: Solomon Islands, 05 July 2005 to 10 December 2005 (non-warlike); Afghanistan, 15 February 2012 to 30 September 2012 (warlike); Iraq, 12 January 2017 to 28 July 2017 (warlike).
Occupational History
As an infantry soldier the veteran carried loads of 30 to 40 kilograms on foot patrols, wore a helmet and body armour for long periods, fired small arms and support weapons and was exposed to blast overpressure from improvised explosive devices, indirect fire and demolitions. Patrol programmes and night pickets produced chronic sleep restriction, and field conditions involved heat, dehydration and irregular meals.
Infantry soldiers carry a high risk of head injury from blast, falls and vehicle incidents, and of psychological trauma from combat, casualties and the handling of the dead. Long deployments separate members from family and commonly place strain on relationships, and analgesics and triptans are freely used in the field to keep soldiers working through pain.
History
Veteran M, an infantry soldier in the Australian Army with established migraine and cluster headache, developed tension-type headache on 21 July 2012 during warlike service in Afghanistan, three days after a concussion from an improvised explosive device blast, while he had posttraumatic stress disorder, insomnia and a recent marital separation. The headache became chronic, and it worsened in June 2017 in Iraq after a second concussion, with ongoing analgesic overuse and topical glyceryl trinitrate treatment.
Timeline
- 12 Mar 2008 — At the garrison health centre the veteran described recurrent unilateral throbbing headaches with nausea and photophobia, lasting 8 to 24 hours, two to three times a month since basic training, triggered by sleep loss, heat and dehydration on exercises. The Medical Officer diagnosed migraine without aura and prescribed sumatriptan 50 mg and paracetamol. Neurological examination was normal. "migraine without aura, sumatriptan prn"
- 04 Aug 2010 — A neurologist assessed bouts of severe right orbital pain lasting 45 to 90 minutes, once or twice nightly for six weeks, with right eye tearing, nasal congestion and restlessness. Episodic cluster headache was diagnosed, coexisting with migraine. High-flow oxygen and subcutaneous sumatriptan 6 mg were prescribed for attacks, with verapamil prevention during bouts. "episodic cluster headache, verapamil"
- 15 Sep 2011 — A psychiatrist diagnosed posttraumatic stress disorder arising from the recovery of drowned bodies and a fatal machete assault he attended during his service in the Solomon Islands in 2005, with symptoms intensifying during pre-deployment training. He reported difficulty getting to sleep and early waking five nights a week since June 2011, and impaired concentration at work. Monthly psychiatry and fortnightly psychology reviews were arranged, and he deployed with a management plan in February 2012. "PTSD, insomnia five nights weekly"
- 18 Jul 2012 — On a foot patrol in Afghanistan an improvised explosive device detonated about 15 metres from the veteran. He was thrown to the ground, struck his helmeted head on a mud wall and lost consciousness for about two minutes. At the role 2 facility the Glasgow Coma Scale score was 14, with confusion and amnesia for the event, and CT of the brain was normal. He received intravenous fentanyl and then oral oxycodone for shoulder and back bruising, ceased on 20 July 2012, and was held for a concussion protocol. "blast concussion, LOC two minutes"
- 24 Jul 2012 — He presented to the Regimental Medical Officer with a constant band-like pressing headache across the forehead and both temples since 21 July 2012, mild to moderate in intensity, without nausea, vomiting or photophobia and not aggravated by walking. The headache was distinct from his migraine and cluster attacks. Pericranial muscle tenderness was present and the neurological examination was normal. His marriage had ended in November 2011, and he was still sleeping poorly. "bilateral pressing headache, not migrainous"
- 12 Nov 2012 — A neurologist reviewed his headache diary since return from Afghanistan. The bilateral pressing headache had occurred on 18 to 22 days a month since late July 2012, lasting hours and at times continuous, and was interfering with work and relationships. MRI of the brain was normal. Chronic tension-type headache was diagnosed alongside migraine and episodic cluster headache, and amitriptyline 10 mg at night was started, with advice to limit analgesics. "chronic tension-type headache confirmed"
- 20 Jun 2017 — During warlike service in Iraq, five days after a second concussion when he fell and struck his head on a concrete blast barrier during a rocket attack on 15 June 2017, the headache became daily and continuous, and severe enough to stop him working. He was taking paracetamol and ibuprofen most days and paracetamol with codeine on three days a week, and was using a glyceryl trinitrate patch for lateral elbow tendinopathy. HIT-6 score 68, up from 58 in 2016. "daily continuous headache, HIT-6 68"
- 14 Feb 2018 — A neurologist confirmed clinical worsening of chronic tension-type headache, with headache on 28 to 30 days a month since June 2017 and superimposed medication overuse. The glyceryl trinitrate patch was ceased, a supervised analgesic withdrawal was arranged and amitriptyline was increased to 50 mg. Neurological examination and repeat imaging were normal. "worsened CTTH, 28 days/month"
Symptoms
At onset the veteran had a constant, bilateral, band-like pressing headache over the forehead and temples, of mild to moderate intensity, without nausea, vomiting, photophobia or aggravation by walking, with tenderness of the scalp and neck muscles. The headache was clearly different from his unilateral throbbing migraine and his short, severe orbital cluster attacks. Over the following three months it occurred on most days and lasted for hours.
He now reports a near-daily pressing headache that worsens with poor sleep, stress and prolonged screen work, impaired concentration and irritability. He has had to give up study, avoids noisy social settings and has reduced his work hours in civilian employment.
Imaging
- 18 Jul 2012 — CT brain (non-contrast): "No intracranial haemorrhage, contusion or skull fracture. Normal study."
- 12 Nov 2012 — MRI brain: "Normal brain parenchyma. No structural lesion, no evidence of diffuse axonal injury and no sinus or cervical abnormality to account for headache."
- 15 Jun 2017 — CT brain (non-contrast): "No acute intracranial abnormality. Small left parietal scalp haematoma."
- 14 Feb 2018 — MRI brain: "Unchanged normal appearance compared with November 2012."
Onset Date
The most likely date of onset of this condition is 21 Jul 2012.
At that date the veteran was serving on warlike service in Afghanistan as a section commander in an infantry battalion, three days after a concussion from an improvised explosive device blast on 18 July 2012. He had posttraumatic stress disorder under monthly psychiatric review, insomnia, a marriage that had broken down eight months earlier, and he was taking sumatriptan and paracetamol several days a week for migraine and cluster headache.
This date is appropriate because his pre-deployment health assessment of 02 February 2012 recorded episodic migraine and cluster headache only, with no other headache type, and he first presented with the new bilateral pressing headache on 24 July 2012, three days after it began. It falls within uninterrupted full-time service and within the deployment.
For the analgesic and triptan factor, the three months before onset run from 21 Apr 2012 to 21 Jul 2012; throughout this period, on deployment, he took sumatriptan on at least two days a week and paracetamol on at least four days a week. For the mental health and stressor factors, the one year before onset runs from 21 Jul 2011 to 21 Jul 2012; posttraumatic stress disorder was diagnosed on 15 September 2011 and managed monthly, and his marital separation occurred in November 2011. His insomnia had been present at least five nights a week since June 2011 and was present on 21 Jul 2012. For the concussion factor, the seven days before onset run from 14 Jul 2012 to 21 Jul 2012; the concussion occurred on 18 Jul 2012, he regained consciousness the same day, and the opioid analgesia was ceased on 20 Jul 2012, so the headache began within seven days of each.
For the worsening factors, the period after onset runs from 21 Jul 2012 to the documented worsening on 20 Jun 2017. The three months before the worsening run from 20 Mar 2017 to 20 Jun 2017, during which he took paracetamol and ibuprofen on at least five days a week and paracetamol with codeine on three days a week in Iraq. The one year before the worsening runs from 20 Jun 2016 to 20 Jun 2017, during which his posttraumatic stress disorder remained under monthly management and his father suffered a disabling stroke in October 2016. The seven days before the worsening run from 13 Jun 2017 to 20 Jun 2017, during which he sustained the second concussion on 15 Jun 2017 and ceased tramadol on 17 Jun 2017. He was wearing a glyceryl trinitrate patch daily from 01 May 2017 to 14 Feb 2018, including at the time of the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Tension-type Headache (ICD-10-AM G44.2), chronic form, under the Statements of Principles concerning tension-type headache, Balance of Probabilities No. 38 of 2018 and Reasonable Hypothesis No. 37 of 2018.
Tension-type headache is the most common primary headache disorder. It is typically bilateral, pressing or tightening rather than pulsating, of mild to moderate intensity and not aggravated by routine physical activity, with little or no nausea. The mechanism involves increased pericranial muscle tenderness and, in the chronic form, central sensitisation of pain pathways, which is promoted by poor sleep, psychological distress, head injury and frequent use of analgesics. The chronic form, with headache on 15 or more days a month for more than three months, causes substantial disability.
The condition began on 21 July 2012 during warlike service in Afghanistan, three days after a blast concussion, in a soldier who already had migraine, cluster headache, posttraumatic stress disorder and insomnia. It became chronic within months and worsened in June 2017 after a second concussion in Iraq.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
21 July 2012.
When did the veteran first present to a health / medical provider for this condition?
24 July 2012.
When was the condition confirmed / formally diagnosed?
12 November 2012.
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 by a neurologist on 12 November 2012 from a prospective headache diary and clinical assessment. Between late July and November 2012 the veteran had episodes of headache lasting hours on 18 to 22 days a month, well above the definitional minimum of ten episodes over at least three consecutive months. The headache was bilateral, pressing and non-pulsating, of mild to moderate intensity and not aggravated by routine activity, meeting all four listed characteristics, and it caused clinically significant impairment of his occupational and social functioning.
Cluster headache and migraine attacks were separately identified and recorded as distinct from the tension-type headache. The normal CT and MRI of the brain, normal neurological examination and normal blood tests excluded structural, inflammatory and systemic causes, and the headache did not arise from exercise or the temporary effect of an extraneous agent. The definition of tension-type headache in subsection 7(2) of the Statements of Principles is met, and the frequency of 15 or more days a month for more than three months meets the definition of chronic tension-type headache.
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 21 July 2012, 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 Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's non-warlike service in the Solomon Islands in 2005, where the trauma underlying his posttraumatic stress disorder occurred, his warlike service in Afghanistan in 2012, where the headache began after a blast concussion, and his warlike service in Iraq in 2017, where it worsened after a second concussion.
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 Tension-Type Headache, No. 38 of 2018
Causative factors
Factor 9(1): for chronic tension-type headache in migraine and cluster headache sufferers only, taking a drug as specified, for at least the three months before the clinical onset of tension-type headache; — MET
- The veteran had migraine, diagnosed on 12 March 2008, and episodic cluster headache, diagnosed by a neurologist on 04 August 2010, and his tension-type headache was confirmed as chronic, occurring on 18 to 22 days a month for more than three months. Throughout the three months before onset, from 21 April 2012 to 21 July 2012, he took sumatriptan on at least two days a week and paracetamol on at least four days a week, both prescribed by Defence medical officers for headaches triggered by heat, dehydration and sleep loss during service. The dispensing record and his deployed medical record document this use.
Worsening factors
Factor 9(2): taking a drug as specified, for at least the three months before the clinical worsening of tension-type headache; — MET
- Throughout the three months before the worsening, from 20 March 2017 to 20 June 2017, the veteran took paracetamol and ibuprofen on at least five days a week and paracetamol with codeine, a combination analgesic, on three days a week, supplied by the deployed medical facility for headache and for service-related elbow and back pain. The neurologist recorded medication overuse superimposed on the worsened tension-type headache on 14 February 2018.
Factor 9(3): undergoing treatment with a nitric oxide donor, at the time of the clinical worsening of tension-type headache; — MET
- A Defence medical officer prescribed a glyceryl trinitrate 1.25 mg/24 hour patch on 01 May 2017 for lateral elbow tendinopathy caused by repetitive weapons handling and load carriage. Glyceryl trinitrate is a listed nitric oxide donor. He was wearing the patch daily when the headache worsened on 20 June 2017, and it was not ceased until 14 February 2018.
Factor 9(4): inability to obtain appropriate clinical management for tension-type headache. — MET
- From January to July 2017 the veteran was deployed in Iraq, where no neurologist, headache clinic or psychologist was available. His request on 02 April 2017 for review of increasing headache frequency and analgesic use could not be met until he returned to Australia, and supervised analgesic withdrawal and preventive dose adjustment were delayed until February 2018. In that period the headache became daily and medication overuse developed. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Tension-Type Headache, No. 37 of 2018
Causative factors
Factor 9(1): for chronic tension-type headache in migraine and cluster headache sufferers only, taking a drug as specified, for at least the three months before the clinical onset of tension-type headache; — MET
- The veteran had both migraine and episodic cluster headache before the onset, and his tension-type headache is chronic. On warlike service in Afghanistan from 15 February 2012 he took sumatriptan on at least two days a week and paracetamol on at least four days a week for migraine provoked by heat, dehydration and broken sleep on patrols, throughout the three months before onset, from 21 April 2012 to 21 July 2012.
Factor 9(2): having a clinically significant disorder of mental health as specified, within the one year before the clinical onset of tension-type headache; — MET
- Posttraumatic stress disorder, a listed disorder, was diagnosed by a psychiatrist on 15 September 2011 and was severe enough to warrant monthly psychiatric and fortnightly psychological management. It arose from recovering drowned bodies and attending a fatal machete assault on non-warlike service in the Solomon Islands in 2005, and it continued through his warlike service in Afghanistan. It was present within the one year before onset, from 21 July 2011 to 21 July 2012.
Factor 9(3): experiencing a category 2 stressor within the one year before the clinical onset of tension-type headache; — MET
- In November 2011 the veteran's marriage broke down and he separated from his wife after relationship counselling failed, the strain having followed his deployment-related posttraumatic stress disorder and pre-deployment absences. This is a problem with a long-term relationship under paragraph (b) of the definition, and its effects were chronic and caused ongoing distress throughout his warlike service in Afghanistan, within the one year before onset, from 21 July 2011 to 21 July 2012. He was also socially isolated from his children by his deployment.
Factor 9(4): having insomnia as specified at the time of the clinical onset of tension-type headache; — MET
- From June 2011 the veteran had difficulty getting to sleep and early waking with inability to return to sleep on five nights a week, recorded by his psychiatrist on 15 September 2011, with impaired concentration at work. In Afghanistan it was compounded by night pickets and broken sleep on patrol. The sleep disturbance had lasted more than three months, at least three nights a week, and was present on 21 July 2012.
Factor 9(5)(a): having concussion or moderate to severe traumatic brain injury within the seven days before the clinical onset of tension-type headache, where tension-type headache has developed within the seven days of: injury to the head; — MET
- On warlike service in Afghanistan on 18 July 2012 the veteran was thrown by an improvised explosive device blast and struck his head on a wall, losing consciousness for about two minutes, with a Glasgow Coma Scale score of 14 and amnesia for the event, meeting the definition of concussion. The tension-type headache began on 21 July 2012, three days after the injury to the head and within the seven days before onset, from 14 July 2012 to 21 July 2012.
Factor 9(5)(b): having concussion or moderate to severe traumatic brain injury within the seven days before the clinical onset of tension-type headache, where tension-type headache has developed within the seven days of: regaining consciousness following the injury to the head; — MET
- The veteran regained consciousness about two minutes after the blast on 18 July 2012 on warlike service in Afghanistan, and the tension-type headache developed on 21 July 2012, three days after he regained consciousness.
Factor 9(5)(c): having concussion or moderate to severe traumatic brain injury within the seven days before the clinical onset of tension-type headache, where tension-type headache has developed within the seven days of: discontinuing medication that impairs the ability to sense or report headache following the injury to the head; — MET
- After the blast of 18 July 2012 the veteran received intravenous fentanyl and then oral oxycodone at the role 2 facility in Afghanistan, opioid analgesics that impair the ability to sense and report headache. The opioid was discontinued on 20 July 2012 and the tension-type headache developed on 21 July 2012, one day later.
Worsening factors
Factor 9(6): taking a drug as specified, for at least the three months before the clinical worsening of tension-type headache; — MET
- On warlike service in Iraq, throughout the three months before the worsening, from 20 March 2017 to 20 June 2017, the veteran took paracetamol and ibuprofen, simple analgesics, on at least five days a week, and paracetamol with codeine on three days a week, issued by the deployed medical facility for headache and service-related musculoskeletal pain. Medication overuse was confirmed by the neurologist on 14 February 2018.
Factor 9(7): having a clinically significant disorder of mental health as specified, within the one year before the clinical worsening of tension-type headache; — MET
- Posttraumatic stress disorder arising from his Solomon Islands and Afghanistan service remained under monthly psychiatric management throughout the one year before the worsening, from 20 June 2016 to 20 June 2017, including telehealth reviews during his warlike service in Iraq. His PCL-5 score was 52 in March 2017.
Factor 9(8): experiencing a category 2 stressor within the one year before the clinical worsening of tension-type headache; — MET
- In October 2016 the veteran's father suffered a disabling stroke, a major deterioration in the health of a family member under paragraph (f) of the definition. The veteran was unable to visit him while deployed on warlike service in Iraq from January 2017 and recorded ongoing distress and worry about his care. This occurred within the one year before the worsening, from 20 June 2016 to 20 June 2017, and its effects were chronic.
Factor 9(9): having insomnia as specified at the time of the clinical worsening of tension-type headache; — MET
- Insomnia with difficulty initiating and maintaining sleep on at least four nights a week persisted from 2011 and was worsened by night alarms and indirect fire attacks during warlike service in Iraq. It was recorded with impairment of his work performance in May 2017 and was present at the worsening on 20 June 2017.
Factor 9(10): undergoing treatment with a nitric oxide donor, at the time of the clinical worsening of tension-type headache; — MET
- During warlike service in Iraq the deployed medical officer prescribed a daily glyceryl trinitrate patch on 01 May 2017 for lateral elbow tendinopathy from repetitive weapons handling. Glyceryl trinitrate is a listed nitric oxide donor, and he was undergoing this treatment when the headache worsened on 20 June 2017.
Factor 9(11)(a): having concussion or moderate to severe traumatic brain injury within the seven days before the clinical worsening of tension-type headache, where tension-type headache has worsened within the seven days of: injury to the head; — MET
- During a rocket attack on warlike service in Iraq on 15 June 2017 the veteran fell while moving to a bunker and struck his head on a concrete blast barrier, losing consciousness for about one minute, with confusion and a scalp haematoma, meeting the definition of concussion. The headache worsened on 20 June 2017, five days after the injury to the head, within the seven days before the worsening, from 13 June 2017 to 20 June 2017.
Factor 9(11)(b): having concussion or moderate to severe traumatic brain injury within the seven days before the clinical worsening of tension-type headache, where tension-type headache has worsened within the seven days of: regaining consciousness following the injury to the head; — MET
- The veteran regained consciousness within about one minute of the head injury on 15 June 2017 in Iraq, and the tension-type headache worsened on 20 June 2017, five days after he regained consciousness.
Factor 9(11)(c): having concussion or moderate to severe traumatic brain injury within the seven days before the clinical worsening of tension-type headache, where tension-type headache has worsened within the seven days of: discontinuing medication that impairs the ability to sense or report headache following the injury to the head; — MET
- After the head injury of 15 June 2017 the deployed medical facility in Iraq gave the veteran tramadol, an opioid that impairs the ability to sense and report headache, for chest wall and shoulder pain from the fall. The tramadol was discontinued on 17 June 2017 and the headache worsened on 20 June 2017, three days later.
Factor 9(12): inability to obtain appropriate clinical management for tension-type headache. — MET
- While on warlike service in Iraq from January to July 2017 the veteran could not obtain neurological review, a preventive medication review or psychological treatment for his headache, and his request of 02 April 2017 was deferred until return to Australia. The headache progressed to daily, with medication overuse, before specialist management in February 2018. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The tension-type headache is a sequela of the veteran's accepted conditions: the concussions sustained on warlike service in Afghanistan in 2012 and Iraq in 2017, his posttraumatic stress disorder and insomnia, and the analgesic and triptan treatment of his service-related migraine and cluster headache.
Unintended Consequence
Met. The worsening of the tension-type headache is in part an unintended consequence of treatment provided by the Commonwealth while the veteran was serving: the glyceryl trinitrate patch prescribed for his service-related elbow tendinopathy, and the frequent analgesics and codeine combination supplied on deployment, which produced medication overuse (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. During his warlike service in Iraq from January to July 2017 the veteran could not obtain neurological review, supervised analgesic withdrawal, preventive medication adjustment or psychological treatment for his headache, and his documented request on 02 April 2017 was deferred until his return to Australia. The headache progressed from 18 to 22 days a month to daily and continuous, with medication overuse, and his HIT-6 score rose from 58 to 68. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational circumstances that prevent access to the treatment a condition requires amount to an inability to obtain appropriate clinical management. The delay of seven months between his return and specialist review in February 2018 is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 12 Mar 2008, Outpatient health record, Medical Officer, Garrison health centre
- 04 Aug 2010, Specialist consultation, Neurologist
- 15 Sep 2011, Psychiatric assessment, Consultant psychiatrist
- 02 Feb 2012, Pre-deployment health assessment, Medical Officer
- 18 Jul 2012, Trauma record and CT brain report, Role 2 facility, Afghanistan
- 24 Jul 2012, Deployed health record, Regimental Medical Officer
- 12 Nov 2012, Specialist consultation and MRI brain report, Neurologist
- 01 May 2017, Deployed health record and prescription, Medical Officer, Iraq
- 15 Jun 2017, Emergency record and CT brain report, Deployed medical facility, Iraq
- 20 Jun 2017, Deployed health record, Medical Officer, Iraq
- 14 Feb 2018, Specialist consultation and MRI brain report, Neurologist
- Statement of Principles concerning Tension-Type Headache (Balance of Probabilities) No. 38 of 2018, Repatriation Medical Authority
- Statement of Principles concerning Tension-Type Headache (Reasonable Hypothesis) No. 37 of 2018, Repatriation Medical Authority
