{"id":"F2018L00563","name":"Statement of Principles concerning tension-type headache (Reasonable Hypothesis) (No. 37 of 2018)","slug":"statement-of-principles-concerning-tension-type-headache-reasonable-hypothesis-no-37-of-2018","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":439607,"registerId":"F2018L00563-fast-fetch-1775955568099","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Statement of Principles concerning tension-type headache (Reasonable Hypothesis) (No. 37 of 2018)","content":"---\nmeta-content-style-type: text/css\nmeta-content-type: application/xhtml+xml; charset=utf-8\nmeta-generator: Aspose.Words for .NET 20.2\n---\n\n?xml version=\"1.0\" encoding=\"utf-8\" standalone=\"no\"?>\n\n\n\n \n\nStatement of Principles\n\nconcerning\n\nTENSION-TYPE HEADACHE (Reasonable Hypothesis)\n\n(No. 37 of 2018)\n\nThe Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.\n\n \n\nDated 27 April 2018\n\n \n\n \n\n \n\n \n\n \n\n| The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:
|\n| --- |\n| 
Professor Nicholas Saunders AO
Chairperson
|\n\n\n \n\n \n\n\nContents\n\n1 Name\n\n2 Commencement\n\n3 Authority\n\n4 Revocation\n\n5 Application\n\n6 Definitions\n\n7 Kind of injury, disease or death to which this Statement of Principles relates\n\n8 Basis for determining the factors\n\n9 Factors that must exist\n\n10 Relationship to service\n\n11 Factors referring to an injury or disease covered by another Statement of Principles\n\nSchedule 1 - Dictionary\n\n1 Definitions\n\n \n\n\n\n\n1 Name\n\nThis is the Statement of Principles concerning tension-type headache (Reasonable Hypothesis) (No. 37 of 2018).\n\n2 Commencement\n\n This instrument commences on 28 May 2018.\n\n3 Authority\n\nThis instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.\n\n4 Revocation\n\nThe Statement of Principles concerning tension-type headache No. 1 of 2010 made under subsection 196B(2) of the VEA is revoked.\n\n5 Application\n\nThis instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.\n\n6 Definitions\n\nThe terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.\n\n7 Kind of injury, disease or death to which this Statement of Principles relates\n\n(1) This Statement of Principles is about tension-type headache and death from tension-type headache.\n\nMeaning of tension-type headache\n\n(2) For the purposes of this Statement of Principles, tension-type headache:\n\n(a) means a condition in which within a 12 month period, there are episodes of headache lasting at least 30 minutes, occurring on at least one day per month for at least three consecutive months, and a minimum of ten episodes occur within that 12 month period; and\n\n(b) has at least two of the following characteristics:\n\n(i) bilateral location;\n\n(ii) pressing/tightening (nonpulsating) quality;\n\n(iii) mild or moderate intensity;\n\n(iv) not aggravated by routine physical activity (such as walking or climbing stairs); and\n\n(c) causes clinically significant distress or impairment of social, occupational, educational, or other important areas of functioning; and\n\n(d) excludes:\n\n(i) cluster headache; \n\n(ii) migraine;\n\n(iii) headache attributable to structural abnormalities or inflammatory disorders of the head and neck;\n\n(iv) headache attributable to systemic disease; and\n\n(v) headache that results from normal physiological stress such as exercise, or the temporary effect of extraneous agents.\n\n(3) While tension-type headache attracts ICD‑10‑AM code G44.2, in applying this Statement of Principles the meaning of tension-type headache is that given in subsection (2).\n\n(4) For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.\n\nDeath from tension-type headache\n\n(5) For the purposes of this Statement of Principles, tension-type headache, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's tension-type headache.\n\nNote: terminal event is defined in the Schedule 1 – Dictionary.\n\n8 Basis for determining the factors\n\nThe Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that tension-type headache and death from tension-type headache can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.\n\nNote: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.\n\n9 Factors that must exist\n\nAt least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting tension-type headache or death from tension-type headache with the circumstances of a person's relevant service:\n\n(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;\n\nNote: chronic tension-type headache and taking a drug as specified are defined in the Schedule 1 - Dictionary. \n\n(2) having a clinically significant disorder of mental health as specified, within the one year before the clinical onset of tension-type headache;\n\nNote: clinically significant disorder of mental health as specified is defined in the Schedule 1 - Dictionary.\n\n(3) experiencing a category 2 stressor within the one year before the clinical onset of tension-type headache;\n\nNote: category 2 stressor is defined in the Schedule 1 - Dictionary.\n\n(4) having insomnia as specified at the time of the clinical onset of tension-type headache;\n\nNote: insomnia as specified is defined in the Schedule 1 - Dictionary. \n\n(5) 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:\n\n(a) injury to the head; or\n\n(b) regaining consciousness following the injury to the head; or\n\n(c) discontinuing medication that impairs the ability to sense or report headache following the injury to the head;\n\n(6) taking a drug as specified, for at least the three months before the clinical worsening of tension-type headache;\n\nNote: taking a drug as specified is defined in the Schedule 1 - Dictionary. \n\n(7) having a clinically significant disorder of mental health as specified, within the one year before the clinical worsening of tension-type headache;\n\nNote: clinically significant disorder of mental health as specified is defined in the Schedule 1 - Dictionary.\n\n(8) experiencing a category 2 stressor within the one year before the clinical worsening of tension-type headache;\n\nNote: category 2 stressor is defined in the Schedule 1 - Dictionary.\n\n(9) having insomnia as specified at the time of the clinical worsening of tension-type headache;\n\nNote: insomnia as specified is defined in the Schedule 1 - Dictionary. \n\n(10) undergoing treatment with a nitric oxide donor, at the time of the clinical worsening of tension-type headache;\n\nNote: nitric oxide donor is defined in the Schedule 1 - Dictionary. \n\n(11) 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:\n\n(a) injury to the head; or\n\n(b) regaining consciousness following the injury to the head; or\n\n(c) discontinuing medication that impairs the ability to sense or report headache following the injury to the head;\n\n(12) inability to obtain appropriate clinical management for tension-type headache.\n\n10 Relationship to service\n\n(1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.\n\n(2) The factors set out in subsections 9(6) to 9(12) apply only to material contribution to, or aggravation of, tension-type headache where the person's tension-type headache was suffered or contracted before or during (but did not arise out of) the person's relevant service.\n\n11 Factors referring to an injury or disease covered by another Statement of Principles\n\nIn this Statement of Principles:\n\n(1) if a factor referred to in section 9 applies in relation to a person; and\n\n(2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;\n\nthen the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.\n\n \n\nSchedule 1 - Dictionary \n\nNote: See Section 6\n\n1 Definitions\n\nIn this instrument:\n\n category 2 stressor means one of the following negative life events, the effects of which are chronic in nature and cause the person to feel ongoing distress, concern or worry:\n\n(a) being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness;\n\n(b) experiencing a problem with a long-term relationship including the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation or divorce;\n\n(c) having concerns in the work or school environment including ongoing disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment;\n\n(d) experiencing serious legal issues including being detained or held in custody, ongoing involvement with the police concerning violations of the law, or court appearances associated with personal legal problems;\n\n(e) having severe financial hardship including loss of employment, long periods of unemployment, foreclosure on a property or bankruptcy;\n\n(f) having a family member or significant other experience a major deterioration in their health; or\n\n(g) being a full-time caregiver to a family member or significant other with a severe physical, mental or developmental disability.\n\nNote: significant other is also defined in the Schedule 1 – Dictionary.\n\n chronic tension-type headache means tension-type headache that lasts for hours or may be continuous, occurring on at least 15 days per month on average, for more than three months.\n\n clinically significant disorder of mental health as specified means one of the following conditions, which is of sufficient severity to warrant ongoing management:\n\n(a) agoraphobia;\n\n(b) anxiety disorder;\n\n(c) obsessive-compulsive disorder;\n\n(d) panic disorder;\n\n(e) posttraumatic stress disorder;\n\n(f) separation anxiety disorder;\n\n(g) social anxiety disorder; or\n\n(h) specific phobia.\n\nNote 1: \"Management\" of the condition may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner.\n\nNote 2: To \"warrant ongoing management\" does not require that any actual management was received or given for the condition.\n\n combination analgesic medication means medication containing a simple analgesic combined with an opioid, butalbital or caffeine.\n\n insomnia as specified means sleep disturbance:\n\n(a) involving difficulty initiating sleep, maintaining sleep or early morning wakening with inability to return to sleep, for at least three nights per week for at least three months; and\n\n(b) causing clinically significant distress or substantial impairment in social, occupational, educational, or other important areas of functioning.\n\n MRCA means the Military Rehabilitation and Compensation Act 2004.\n\n nitric oxide donor means a pharmacologically active substance that releases nitric oxide in vivo or in vitro and includes amyl nitrate, glyceryl trinitrate, isosorbide mononitrate, isosorbide dinitrate, sodium nitroprusside, mannitol hexanitrate and nitrous oxide.\n\n relevant service means:\n\n(a) operational service under the VEA;\n\n(b) peacekeeping service under the VEA;\n\n(c) hazardous service under the VEA;\n\n(d) British nuclear test defence service under the VEA;\n\n(e) warlike service under the MRCA; or\n\n(f) non-warlike service under the MRCA.\n\nNote: MRCA and VEA are also defined in the Schedule 1 - Dictionary.\n\n significant other means a person who has a close family bond or a close personal relationship and is important or influential in one's life.\n\n taking a drug as specified means:\n\n(a) taking a simple analgesic on at least three days per week; or\n\n(b) taking a triptan, ergotamine, an opioid, or a combination analgesic medication on at least two days per week.\n\nNote: combination analgesic medication and triptan are also defined in the Schedule 1 – Dictionary.\n\n tension-type headache—see subsection 7(2).\n\n terminal event means the proximate or ultimate cause of death and includes the following:\n\n(a) pneumonia;\n\n(b) respiratory failure;\n\n(c) cardiac arrest;\n\n(d) circulatory failure; or\n\n(e) cessation of brain function.\n\n triptan means a 5-hydroxytryptamine receptor agonist.\n\n VEA means the Veterans' Entitlements Act 1986.\n\n \n","sortOrder":0}],"analysis":{"kimi_summary":{"content_quality":"ok","complexity_score":6,"scope_assessment":{"changed":false,"description":"This is a standard replacement instrument (revoking No. 1 of 2010) that maintains the established scope of Repatriation Medical Authority determinations. It updates the ICD-10-AM reference to the Tenth Edition and refines definitions, but does not expand beyond the original purpose of establishing medical criteria for service-connected tension-type headache claims."},"complexity_factors":["18 defined terms in Schedule 1, many with nested sub-definitions (e.g., 'taking a drug as specified' cross-references 'combination analgesic medication' and 'triptan')","Dual pathway structure: separate factors for 'clinical onset' (new condition) versus 'clinical worsening' (aggravation of pre-existing condition) with partially overlapping but distinct criteria","Conditional logic with multiple qualifiers: Factor 9(1) applies only to 'chronic tension-type headache in migraine and cluster headache sufferers only' — a triple qualification","Temporal precision requirements throughout: 'within the one year before', 'at least three months before', 'within the seven days before', 'at the time of'","Cross-referencing to external classification systems (ICD-10-AM Tenth Edition) and other Statements of Principles via section 11","Exclusion clauses in the definition of tension-type headache that rule out 5 other categories of headache","Section 10 creates a bifurcated application: factors 9(6)-9(12) only apply to aggravation cases where the condition pre-existed service"],"plain_english_summary":"This instrument sets strict medical-legal rules for when tension-type headaches can be accepted as connected to Australian military service, defining required clinical criteria (frequency, duration, symptoms, and functional impact) and identifying specific service-related circumstances that can establish a reasonable hypothesis of causation. \n\nIt affects veterans and current/former defence members claiming under the VEA or MRCA and Department of Veterans' Affairs decision-makers — raising the evidentiary bar for service connection and guiding consistent claim outcomes."},"flash_summary":{"complexity_score":5,"scope_assessment":{"changed":true,"description":"This instrument expressly revokes the prior Statement of Principles concerning tension‑type headache No. 1 of 2010 (s4) and replaces it with updated definitions and a reorganised set of causation factors. The 2018 Statement broadens and clarifies the factors that can raise a reasonable hypothesis by adding or specifying items such as insomnia as specified (Schedule 1), treatment with nitric oxide donors at time of worsening (s9(10), Schedule 1), and \"inability to obtain appropriate clinical management\" (s9(12)). It also sets explicit timing windows (for example 7 days for concussion/TBI and 1 year for mental health disorders) and clarifies application limits where the condition pre‑existed service (s10(2)). Those changes broaden the evidentiary paths by which claimants can establish a service link compared with a simple, older definition; they therefore change scope in practice from a purely definitional update to a substantive re‑scoping of causation factors and evidentiary thresholds."},"complexity_factors":["12+ defined terms in Schedule 1 (category 2 stressor; chronic tension‑type headache; clinically significant disorder of mental health; combination analgesic medication; insomnia as specified; nitric oxide donor; relevant service; significant other; taking a drug as specified; terminal event; triptan; others)","Twelve discrete factor lines in section 9 with varied timing and application (s9(1)–s9(12))","Multiple timing windows and thresholds (e.g. concussion/TBI within 7 days; mental health disorder within 1 year; medication use thresholds of days per week or months)","Conditional limitation in s10(2) restricting s9(6)–s9(12) to material contribution/aggravation where condition pre‑existed service","Cross‑reference dependency to other Statements of Principles (s11), increasing document interdependence","Several clinically subjective terms requiring medical judgment (e.g. \"clinically significant distress/impairment\", \"inability to obtain appropriate clinical management\")","Revocation and replacement of an earlier instrument (s4) — requires comparative reading for practitioners familiar with the prior text"],"plain_english_summary":"**What this instrument does (mechanics)**\n\n- Replaces the earlier Statement of Principles for tension‑type headache and sets out the medical criteria that the Repatriation Medical Authority (RMA) has determined can establish a \"reasonable hypothesis\" that a veteran’s tension‑type headache (or death contributed to by it) is related to their relevant service. (see sections 3, 4, 5, 7, 8 and 9)\n\n- Gives a working medical definition of \"tension‑type headache\" for claims purposes, including frequency, duration and clinical characteristics, and lists conditions that are excluded (for example migraine, cluster headache, structural causes). (s7(2)–(4))\n\n- Lists the specific factual/medical factors that, if present and related to relevant service, are sufficient to raise a reasonable hypothesis connecting the condition (or death from it) with service. These factors include recent concussion/traumatic brain injury, certain patterns of drug use, specified mental health disorders, certain chronic stressors, insomnia, treatment with nitric oxide donors, inability to obtain appropriate clinical management, and timing requirements for onset or worsening. (s9 and Schedule 1 definitions)\n\n- Explains how those factors must be linked to a person’s \"relevant service\" (the kinds of service covered under the VEA and MRCA) and limits how some factors are applied where the headache pre‑existed service (material contribution/aggravation rules). (s10)\n\n- Provides that if a listed factor refers to another injury/disease already covered by a different Statement of Principles, that other Statement applies for the details of how that factor is treated. (s11)\n\n\n**Who this affects**\n\n- Primary: veterans, members of the Defence Force and other persons whose claims fall under the Veterans’ Entitlements Act 1986 (VEA) or the Military Rehabilitation and Compensation Act 2004 (MRCA). (s5)\n- Secondary: decision‑makers at the Department of Veterans’ Affairs (DVA) who assess causal connection for claims; treating clinicians and independent medical examiners who provide evidence; and legal/advocate representatives preparing claims.\n\n\n**Why it matters (purpose claims and practical effect)**\n\n- The RMA states it relies on medical‑scientific evidence in deciding the listed factors can link tension‑type headache to relevant service. (s8)\n- Mechanically, the Statement does two things: (a) it defines the medical condition in claim terms (s7), and (b) it lists specific, time‑bound clinical and life‑event factors that, if shown and related to service, are sufficient to raise a reasonable hypothesis of service connection (s9). That changes what evidence claimants and clinicians need to present and how decision‑makers evaluate causation.\n\n\n**Costs, incentives, trade‑offs and implementation issues**\n\n- Evidence and compliance burden (who pays/produces evidence): Claimants must produce contemporaneous or retrospective clinical records, witness statements, or other evidence to show that a listed factor existed within the specified time windows (for example, concussion within seven days of onset or mental health disorder within one year before onset). Administrative and evidentiary costs fall on claimants and on DVA (processing and medical review). (s9, s10)\n\n- Bureaucratic discretion and medical judgment: Several key terms require clinical judgement—\"clinically significant distress or impairment,\" \"inability to obtain appropriate clinical management,\" and the listed mental health diagnoses being of sufficient severity to \"warrant ongoing management.\" Those invite interpretive decisions by medical assessors and DVA decision‑makers and can produce variable outcomes depending on how strictly they are applied. (s7(2)(c); Schedule 1 definitions)\n\n- Timing and causation rules create behavioural incentives: The Statement sets short windows for some causes (e.g. concussion or moderate–severe TBI within seven days of onset/worsening (s9(5), s9(11))) and minimum exposure patterns for medication overuse (Schedule 1). This may incentivise better contemporaneous documentation by clinicians and claimants, and may influence prescribing or record‑keeping practices by treating doctors where future claims are a realistic possibility.\n\n- Effects on private medical practice and commercial markets: There is no direct regulatory effect on private businesses or markets. Indirectly, clinicians may alter record keeping and prescribing practices; private insurers are not directly addressed. The instrument does not change prices, ownership, competition, or trade. (See Schedule 1 definitions of drugs and treatment factors.)\n\n- Concentrated benefits and diffuse costs: The beneficiaries are claimants who can meet the discrete factors (concentrated). The fiscal cost—if more claims are accepted because of the Statement—would be borne by the government (taxpayers) and absorbed by DVA budget lines (diffuse). The instrument does not create a new entitlement; it changes evidentiary thresholds for establishing a causal link.\n\n- Substitution and unintended consequences: The Statement may shift claimant behaviour toward documenting stressors, sleep problems, medication use and access to care. It may also place a premium on obtaining specialist letters that describe the timing and severity of mental health issues, insomnia or medication use.\n\n- Interaction with other Statements and overlap risk: Section 11 requires factors that refer to other injuries/diseases to be governed by the other relevant Statement of Principles, meaning claim assessments can require cross‑reference to other instruments and medical evidence (complexity and potential delay). (s11)\n\n\n**Who decides, who pays, and likely behavioural changes**\n\n- Who decides: The RMA determines these principles (s3). DVA decision‑makers and their medical assessors apply them to individual claims. Courts may review outcomes on legal grounds.\n\n- Who pays: Any accepted claims are paid through the compensation and benefits frameworks under the VEA or MRCA—ultimately public funds administered by DVA. (s5, s8)\n\n- Behaviour changes expected: better clinical record‑keeping on onset/worsening timing and specified factors; potential changes in prescribing practice or documentation by clinicians; claimants may compile evidence specifically mapped to the stated factors; DVA will rely on these stated factors to raise or reject reasonable hypotheses.\n\n\n**Key provisions to look at when preparing or assessing a claim**\n\n- Definition of tension‑type headache (s7(2)–(4)).\n- Complete list of factors that can raise a reasonable hypothesis (s9 and Schedule 1 definitions).\n- How factors must relate to relevant service and limits for aggravation/material contribution (s10).\n- Cross‑reference rule to other Statements of Principles (s11).\n\n\n**Practical note on evidentiary pitfalls and implementation risk**\n\n- Expect disputes around subjective or retrospectively‑assessed concepts (\"clinically significant\", \"inability to obtain appropriate clinical management\", episodic timing). These are common sources of inconsistent outcomes and will increase reliance on contemporaneous clinical records and quality medical opinions. (s7(2)(c); Schedule 1 definitions)\n\n\nReferences: sections cited above are from this Statement of Principles concerning tension‑type headache (No. 37 of 2018)."},"flash_summary_failed":{"failed":true,"reason":"Unauthenticated. Configure AI_GATEWAY_API_KEY or use a provider module. Learn more: https://ai-sdk.dev/unauthenticated-ai-gateway","source":"analysis-cron"}},"importantCases":[],"_links":{"self":"/api/acts/statement-of-principles-concerning-tension-type-headache-reasonable-hypothesis-no-37-of-2018","history":"/api/acts/statement-of-principles-concerning-tension-type-headache-reasonable-hypothesis-no-37-of-2018/history","analysis":"/api/acts/statement-of-principles-concerning-tension-type-headache-reasonable-hypothesis-no-37-of-2018/analysis","conflicts":"/api/acts/statement-of-principles-concerning-tension-type-headache-reasonable-hypothesis-no-37-of-2018/conflicts","importantCases":"/api/acts/statement-of-principles-concerning-tension-type-headache-reasonable-hypothesis-no-37-of-2018/important-cases","documents":"/api/acts/statement-of-principles-concerning-tension-type-headache-reasonable-hypothesis-no-37-of-2018/documents"}}