Statement of Principles concerning tension-type headache (Balance of Probabilities) (No. 38 of 2018)

The instrument operates around a small set of interlocking legal and medical concepts: the statutory authority to make Statements of Principles; the definition of the injury/disease for claims purposes; the evidentiary/casual factors that establish a connection with relevant service; the temporal relationship between service and disease; and cross‑application with other SoPs.

Authority and scope: The Repatriation Medical Authority made the instrument under s196B(3) of the VEA, and it is explicitly directed to claims covered by s120B of the VEA or s339 of the MRCA (s3, s5). It revokes the previously enumerated SoP from 2010 (s4).

Definition of tension‑type headache: The instrument specifies a diagnostic definition for claims work rather than relying solely on ICD coding. Subsection 7(2) sets threshold criteria: over a 12 month period, episodes lasting at least 30 minutes, on at least one day per month for at least three consecutive months, and a minimum of ten episodes in the 12 months; plus at least two listed characteristics (bilateral location, pressing/tightening nonpulsating quality, mild or moderate intensity, not aggravated by routine physical activity) and clinically significant distress or impairment (s7(2)(a)-(c)). Subsection 7(2)(d) lists exclusions (cluster headache, migraine, structural or inflammatory causes, systemic disease, and headaches arising from normal physiological stress or temporary extraneous agents). The Schedule defines chronic tension‑type headache as 15+ days per month on average for more than three months (Schedule 1, definition of chronic tension‑type headache).

Causation and factors: Section 8 states the Authority’s view of causation: based on sound medical‑scientific evidence, it is more probable than not that tension‑type headache and death from it can be related to relevant service (s8). Section 9 then lists the specific factors, each of which must exist for service connection to be established on the balance of probabilities. The Schedule defines key terms used in those factors, including "taking a drug as specified", "combination analgesic medication", "nitric oxide donor", "triptan", and "relevant service".

Temporal and relationship rules: Section 10 requires that any factor in s9 be related to the person’s relevant service (s10(1)). Section 10(2) narrows application of factors in s9(2)-(4): they apply only to material contribution or aggravation where the tension‑type headache was suffered or contracted before or during (but did not arise out of) the person’s relevant service. That is a limiting rule on when those factors can be used to show material contribution or aggravation.

Interaction with other SoPs: Section 11 provides that if a s9 factor refers to an injury or disease covered by another SoP made under s196B(3), then the factors in that other SoP apply according to its terms as in force (s11). This creates an explicit cross‑reference mechanism between SoPs.

Death and terminal events: The instrument treats death from tension‑type headache as including death from a terminal event that was contributed to by the tension‑type headache. The Schedule defines terminal events broadly (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function) (s7(5), Schedule 1).

Medical coding: The instrument acknowledges the ICD‑10‑AM code G44.2 but clarifies that, for the instrument’s purposes, the statutory textual definition controls (s7(3)-(4)).

The instrument applies to potential claimants under two statutory regimes: claims to which section 120B of the Veterans’ Entitlements Act 1986 applies, and claims to which section 339 of the Military Rehabilitation and Compensation Act 2004 applies (s5). Those are the statutory gateways that determine the set of claims to which this SoP is operationally relevant.

Practitioners engaged in preparing or deciding claims under those statutory provisions are affected because the SoP provides the medical‑factual criteria that must be applied in establishing service connection on the balance of probabilities. The instrument itself does not name decision‑makers or specify procedural steps, but by its terms it is intended to be applied in the adjudication of claims that fall under the cited provisions (s3, s5, s8). For example, where a claimant advances a claim for compensation or benefit premised on tension‑type headache, the adjudicator will consult this SoP to determine whether the required factual factors and service link exist.

Veterans or former members of the Forces will be directly affected if they seek recognition of tension‑type headache as connected with relevant service. The SoP defines who constitutes relevant service for these purposes: eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA (Schedule 1). The exclusions embedded in that definition mean that some categories of service are explicitly outside the definition of "relevant service" used by this instrument. This has a direct effect on which service histories can be said to satisfy the statutory linkage requirement (Schedule 1, definition of relevant service).

Clinicians who provide evidence for claims are implicated because the SoP sets measurable thresholds that medical evidence must square with, for instance episode frequency and drug exposure timing. The instrument’s requirements concerning drug exposure (Schedule 1 definition of "taking a drug as specified") and chronicity (Schedule 1 definition of "chronic tension‑type headache") give claimants and clinicians specific factual elements to document.

Finally, other claimants whose conditions are referenced within these factors may be affected indirectly through s11. If a s9 factor refers to another injury or disease covered by a different SoP, the factors in that other SoP apply under its own terms. This can import requirements or definitions from other SoPs into the assessment of a tension‑type headache claim.

The instrument does not create statutory obligations in the form of criminal sanctions or new administrative powers. Rather, it defines the legal and medical yardsticks used to determine whether tension‑type headache or death from it is connected with relevant service on the balance of probabilities. The immediate "duties" and "rights" are therefore evidentiary and functional in the claims context.

Right to rely on the SoP: Claimants have the practical right to have their tension‑type headache claims assessed against these specific criteria when their claims fall under s120B VEA or s339 MRCA (s5). The SoP sets the standards that will be used in that assessment, including the definitional elements and the enumerated factors in s9. Where a claimant can establish a factor in s9 and show it is related to their relevant service, the SoP posits that, on the balance of probabilities, the condition can be related to service (s8, s9).

Duty to demonstrate a factor and service relation: The instrument requires that at least one of the s9 factors exist and that it be related to the person’s relevant service (s9, s10(1)). Where the factor relates to material contribution or aggravation and the condition was suffered or contracted before or during (but did not arise out of) relevant service, the instrument limits use of s9(2)-(4) to those circumstances (s10(2)). Practically, this places a duty on claimants to identify and prove both the factual factor and its relationship to their relevant service timeline consistent with the instrument’s terms.

Duty to apply cross‑SoP rules: If a s9 factor refers to another injury or disease that has its own SoP, the practitioner must apply the factors of that other SoP in accordance with its terms (s11). This creates a duty on decision‑makers and advisers to cross‑check relevant SoPs.

Medical definition duty: The detailed diagnostic elements in s7(2) and Schedule 1 provide a duty‑like effect on medical evidence: to fit the instrument’s criteria a claimant’s condition must meet the specified frequency, duration, symptom character and exclusion criteria. For instance, chronic tension‑type headache carries an explicit numeric threshold (15 or more days per month on average, >3 months) in the Schedule.

No penal powers or sanctions in this instrument: The SoP does not itself impose penalties for non‑compliance with medical management or drug regimens. Rather, one of the factors (s9(4)) permits service connection where there was inability to obtain appropriate clinical management for tension‑type headache. The instrument does not set out enforcement mechanisms for that factor; it simply recognises that inability to obtain appropriate management may be a basis for establishing connection.

Burden of proof and standard: The instrument is explicit that its conclusions are expressed on the balance of probabilities, as is standard for civil claims: the Authority’s view is that it is more probable than not that tension‑type headache and death from it can be related to relevant service, subject to the presence of the factors (s8, s9).

The instrument itself contains no criminal or civil penalties, and it does not create an enforcement regime. It is a Statement of Principles defining medical and factual criteria for adjudicating claims under the VEA and MRCA. There are consequently no penalties prescribed within this instrument for breach or non‑compliance.

Enforcement in practice occurs through the claims process under the cited statutes. The instrument applies to claims to which s120B of the VEA or s339 of the MRCA applies (s5), and those statutory provisions and their administrative processes provide the procedural and enforcement framework for benefits and entitlements. The SoP functions as a substantive input into that adjudicative machinery by specifying which medical and factual circumstances will, on the balance of probabilities, establish a connection between tension‑type headache (or death from it) and relevant service (s8, s9).

Because the instrument contains specific definitional thresholds, the practical enforcement effect is evidentiary. Decision‑makers will assess whether the claimant’s situation meets the thresholds in s7 and Schedule 1 and whether one of the s9 factors exists and is related to relevant service (s9, s10). Where evidence does not meet those thresholds, the claimant will not obtain a finding of service connection under this SoP; that outcome is the operative enforcement result, but it is achieved through administrative decision‑making under the VEA or MRCA rather than by penalties in this instrument.

The instrument also contains a revocation clause that withdraws the earlier SoP (No. 2 of 2010) (s4). That revocation changes which Statement of Principles governs claims from its commencement date onwards (s2). There is no provision in this instrument for penalties or sanctions against parties that relied on the earlier SoP prior to revocation. Any retrospective or transitional consequences would depend on the statutory and administrative rules governing claims and adjudication under the VEA and MRCA, not on this instrument itself.

Finally, s11’s cross‑application mechanism means that enforcement outcomes for a particular factor might depend on the provisions of another SoP if the factor refers to another injury or disease covered by that SoP. That could change the factual requirements relevant to a claim and thereby affect the outcome, but again this is a matter of adjudication rather than direct statutory penalty in this instrument.

The SoP is made under the VEA power to determine Statements of Principles (s3 refers to subsection 196B(3) of the VEA). It applies specifically to claims governed by section 120B of the VEA or section 339 of the MRCA (s5). Those statutory references place the SoP within the broader legislative framework governing veterans’ entitlements and military compensation claims.

Interaction with other Statements of Principles: Section 11 explicitly provides for inter‑SoP interaction. If a s9 factor refers to an injury or disease covered by another SoP determined under s196B(3) of the VEA, then the factors in that other SoP apply according to its terms as in force from time to time (s11). This creates a direct mechanism whereby the factual criteria of other SoPs can be imported into the assessment of a tension‑type headache claim when relevant.

Relation to ICD coding and external standards: The instrument acknowledges the ICD‑10‑AM code G44.2 for tension‑type headache but states that, in applying the instrument, the statutory textual definition in s7(2) governs (s7(3)-(4)). The instrument also references the specific edition and effective date of the ICD‑10‑AM used (Tenth Edition, effective date 1 July 2017), but that reference is descriptive and the instrument clarifies that the code is secondary to the instrument’s own definition (s7(3)-(4)).

Temporal and service‑type exclusions: The definition of "relevant service" in the Schedule excludes operational service, hazardous service and British nuclear test defence service for certain categories under the VEA, while including peacetime service under the MRCA (Schedule 1). This means the SoP’s application is constrained by the statutory categories of service set out in those Acts. Practitioners must cross‑check whether the claimant’s service record fits the Schedule’s definition of relevant service before applying the SoP.

Relationship with medical practice and clinical management: The SoP recognises inability to obtain appropriate clinical management as a factor (s9(4)). That is a point of intersection between administrative law and healthcare delivery. Determinations about whether a person was unable to obtain appropriate clinical management will require evidence about the availability or accessibility of care, but the instrument itself does not define procedural mechanisms for assessing that evidence. Any assessment will occur within the VEA/MRCA claim adjudication framework.

Revocation and temporal application: The revocation clause (s4) removes the earlier 2010 SoP and replaces it with the 2018 instrument from the commencement date (s2). How the new instrument interacts with claims that predate commencement is a question for the application rules of the VEA and MRCA and for decision‑makers; the instrument itself sets the operative criteria from its commencement date and repeals the earlier SoP.

This instrument is the Statement of Principles concerning tension‑type headache (Balance of Probabilities) No. 38 of 2018. It is dated 27 April 2018 and commenced on 28 May 2018 (s2, front matter). The text contains an explicit revocation of the Statement of Principles concerning tension‑type headache No. 2 of 2010 (s4). That is the only amendment or revocation recorded within this instrument.

The instrument also references external material that is time‑specific. It cites the ICD‑10‑AM Tenth Edition, effective date 1 July 2017, and identifies the ISBN and copyright holder for that edition (s7(3)-(4)). The instrument’s reference to that edition fixes which ICD code is being acknowledged at the time the SoP was made. The SoP, however, clarifies that the statutory definition in s7(2) governs for claims purposes, which limits reliance on ICD updates as a substitute for the instrument’s textual criteria (s7(3)).

There are no recorded subsequent amendments, variations, or replacement SoPs contained within the text of this instrument. Section 11 contemplates that other SoPs may be altered "from time to time" and that their factors, as in force, will apply where relevant, but that does not change the 2018 instrument itself. Any later amendments to this particular SoP would appear as separate instruments under the authority of the VEA and would need to be consulted in their own right.

Because the instrument revokes the 2010 SoP, advisers must be attentive to which version of the SoP applies to a particular claim based on timing. The instrument does not itself set out transitional rules for claims that straddle the revocation and commencement dates; those transitional consequences must be resolved within the broader statutory claim framework or by reference to the administrative practices of the decision‑making bodies.

This instrument contains no report, reference or list of court or tribunal decisions. It neither cites case law nor records litigation concerning its provisions. The SoP is an administrative medical instrument and the text does not include or summarise any judicial consideration of its terms.

Practitioners seeking litigation history or precedents that interpret or apply this SoP must therefore consult the relevant case law and tribunal decisions outside this instrument. The instrument itself provides no internal litigation register, and it does not identify past determinations that influenced its drafting beyond the Authority’s statement that its view is founded on "sound medical‑scientific evidence" (s8). Any judicial or tribunal treatment of this SoP , for instance, whether decision‑makers properly applied the definitions and the s9 factors in particular fact patterns , will be found in external sources, which are not contained in this instrument.

Because s11 imports the factors of other SoPs when a s9 factor refers to another injury or disease, litigation that interprets those other SoPs may be relevant to the application of this SoP. Again, this instrument does not catalogue such litigation. The absence of litigation content in the instrument means that anyone relying on it for case preparation must undertake a separate search for administrative decisions, tribunal or court judgments that consider the operation or interpretation of this or related SoPs.

There are several technical points and traps for practitioners embedded in the instrument’s wording that could materially affect claim outcomes.

Textual definition controls over ICD code: Although the instrument acknowledges that tension‑type headache attracts ICD‑10‑AM code G44.2, s7(3) expressly states that for the purposes of this SoP the meaning of tension‑type headache is that given in s7(2). In other words, the ICD code is not dispositive. Practitioners must map clinical evidence to the statutory criteria in s7(2) rather than relying solely on ICD coding in medical records.

Strict frequency, duration and episode thresholds: The diagnostic criteria in s7(2)(a) require episodes 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 in a 12 month period. These are numerical thresholds. Similarly, the Schedule’s definition of chronic tension‑type headache requires 15 or more days per month on average, for more than three months. Claims that assert tension‑type headache but cannot document those thresholds risk failing the SoP’s definitional test.

Symptom characteristics and exclusion list: The SoP requires at least two of four characteristics (bilateral location; pressing/tightening nonpulsating quality; mild/moderate intensity; not aggravated by routine physical activity), plus clinically significant distress or impairment (s7(2)(b)-(c). It also expressly excludes cluster headache, migraine, headaches from structural or inflammatory disorders, systemic disease, and headaches resulting from normal physiological stress or temporary extraneous agents (s7(2)(d)). Where a claimant’s records show overlapping features with migraine or other excluded diagnoses, careful medical tying‑down to the SoP criteria will be necessary.

"Relevant service" exclusions: The Schedule defines relevant service narrowly in certain respects. Eligible war service is included other than operational service; defence service is included other than hazardous service and British nuclear test defence service; and peacetime service under the MRCA is included. The exclusion of operational, hazardous and British nuclear test defence service in parts of the VEA categories is a critical point to check in a claimant’s service record. Misclassifying a person’s service as "relevant service" when it falls into one of those excluded categories would be a fundamental error.

Temporal limitation on certain factors: Section 10(2) restricts application of s9(2)-(4) to cases of material contribution or aggravation where the tension‑type headache was suffered or contracted before or during (but did not arise out of) relevant service. This means that those factors cannot be used to show material contribution or aggravation if the tension‑type headache arose out of service. Practitioners must therefore carefully characterise whether the condition arose out of, or was merely suffered/contracted before or during, service.

Drug exposure definitions are prescriptive: The Schedule’s definition of "taking a drug as specified" sets precise frequency thresholds: a simple analgesic on at least three days per week, or a triptan, ergotamine, an opioid, or a combination analgesic medication on at least two days per week. A "combination analgesic medication" is separately defined. Claims that rely on drug exposure must match those frequency thresholds and the timing requirement in s9 (three months before onset or worsening as applicable). Failure to document dosage, frequency or timing to the instrument’s thresholds will undermine reliance on the drug‑related factors.

Death linkage requires contribution to a terminal event: For death claims, the instrument counts death from a terminal event or condition that was contributed to by the person’s tension‑type headache (s7(5)). Terminal event is defined by example in the Schedule (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function). Practitioners must therefore show not only that tension‑type headache existed, but that it contributed to one of these terminal events or similar proximate causes of death.

Cross‑SoP complexity: Section 11 means that if a s9 factor refers to an injury or disease covered by another SoP, the practitioner must then apply that other SoP’s factors in accordance with its terms. This can import unexpected definitions or thresholds and increases the complexity of proof.

No procedural detail on "inability to obtain appropriate clinical management": Section 9(4) recognises inability to obtain appropriate clinical management as a factor but provides no procedural guidance on what evidence satisfies that criterion. Claimants and advisers should anticipate that this will require factual proof about availability or access to care, but the instrument does not define the standards or evidentiary mechanisms.

Revocation effect: The 2010 SoP was revoked (s4). Where earlier decisions were made under the revoked SoP, practitioners should verify which SoP applies to a given claim based on timing, as the operative factual criteria changed with the 2018 instrument.

The SoP sets objective, textually specified elements that claimants and advisers must address. Compliance, in the claims context, means assembling medical and factual evidence that satisfies the definitional thresholds in s7 and the existence and service‑relation of at least one s9 factor in accordance with s10 and the Schedule.

Step 1 , Establish the medical case using the instrument’s definition:

• Map the claimant’s clinical history to s7(2). Show that, within a 12 month period, the episode frequency, duration, and minimum number of episodes are met (s7(2)(a)).
• Show that at least two of the specified symptom characteristics are present and that the condition causes clinically significant distress or impairment (s7(2)(b)-(c)).
• Demonstrate that the condition does not fall within the express exclusions in s7(2)(d). Where records indicate overlapping diagnoses (for example migraine), obtain a treating clinician’s contemporaneous opinion addressing why the presentation meets the SoP definition rather than an excluded category.
• For chronic tension‑type headache claims, ensure the complaint meets the Schedule’s chronicity threshold: 15 or more days per month on average for more than three months (Schedule 1).

Step 2 , Identify and prove at least one factor in s9:

• For factor s9(1): Where the claimant is a migraine or cluster headache sufferer and alleges chronic tension‑type headache, document taking a specified drug for at least the three months before clinical onset. The Schedule defines "taking a drug as specified" with precise frequency thresholds (simple analgesic at least three days per week; triptan, ergotamine, opioid or combination analgesic at least two days per week). Ensure timing and frequency are supported by contemporaneous notes, prescriptions, pharmacy records or clinician affidavit.
• For factor s9(2): To rely on drug exposure for clinical worsening, document taking the specified drug for at least three months before the clinical worsening event. Again, corroborate with medical records and prescription history.
• For factor s9(3): If relying on exposure to a nitric oxide donor at the time of clinical worsening, document the specific donor and timing. The Schedule lists included substances (amyl nitrate, glyceryl trinitrate, isosorbide mononitrate, isosorbide dinitrate, sodium nitroprusside, mannitol hexanitrate, nitrous oxide).
• For factor s9(4): Where inability to obtain appropriate clinical management is asserted, gather evidence of attempts to obtain care, reasons care was not obtained, and the resulting clinical deterioration. The SoP does not define evidentiary standards for this factor, so contemporaneous evidence will be important.

Step 3 , Link the factor to relevant service:

• Confirm that the claimant’s service falls within the instrument’s definition of "relevant service" (Schedule 1). Check whether the service was eligible war service (excluding operational service), defence service (excluding hazardous service and British nuclear test defence service) under the VEA, or peacetime service under the MRCA.
• Demonstrate the temporal relationship required by s10. For factors s9(2)-(4) relied upon as material contribution or aggravation, show that the tension‑type headache was suffered or contracted before or during (but did not arise out of) relevant service. If the condition arose out of service, these factors may not be applicable for material contribution or aggravation per s10(2).

Step 4 , Cross‑check other SoPs:

• If any s9 factor refers to another injury or disease that has its own SoP, identify that SoP and apply its factors and definitions in accordance with s11. This may alter the evidence required or the thresholds to be met.

Step 5 , Prepare medico‑legal linkage:

• Although the instrument frames its conclusions on the balance of probabilities, the claimant should obtain clinician statements that expressly address the SoP criteria, mapping clinical facts to the statutory language (s7, s9, Schedule 1). Where the claimant relies on drug exposure or inability to obtain care, the clinician should comment on timing, frequency and causal plausibility consistent with the SoP.

Step 6 , Death claims:

• If the claim concerns death, demonstrate that the tension‑type headache contributed to a terminal event as defined in the Schedule (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function) or a similar proximate cause. Medical and coronial records that link the decedent’s headache condition to the terminal event will be necessary to meet s7(5).

Step 7 , Administrative housekeeping:

• Be alert to the commencement date of this SoP (28 May 2018) and that it revoked the 2010 SoP (s2, s4). Confirm which SoP applies to the claim based on timing and any relevant transitional rules in the VEA or MRCA administrative framework.

Evidence types that will assist compliance:

• Contemporaneous clinical notes recording episode frequency, duration, characteristics and functional impairment.
• Prescriptions, pharmacy dispensing records, or clinician notes that identify drug names, dosages, frequencies and their timing relative to onset or worsening.
• Statements from treating clinicians that explicitly address each relevant element of the SoP.
• Service records that establish the type and timing of service to confirm "relevant service" under the Schedule.
• For s9(4), contemporaneous evidence of attempts to access clinical care, referrals, waiting lists, geographic or operational access problems, and resulting clinical consequences.

In short, compliance requires mapping clinical facts precisely to the SoP’s textual thresholds, documenting timing in relation to service, and, where relevant, integrating other SoPs per s11. The SoP’s prescriptive thresholds for episode frequency, chronicity and drug exposure make the nature and quality of evidence decisive.