Statement of Principles concerning CLUSTER HEADACHE (Reasonable Hypothesis) (No. 57 of 2018) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986. Dated 22 June 2018 The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of: Professor Nicholas Saunders AO Chairperson Contents 1 Name 2 Commencement 3 Authority 4 Repeal 5 Application 6 Definitions 7 Kind of injury, disease or death to which this Statement of Principles relates 8 Basis for determining the factors 9 Factors that must exist 10 Relationship to service 11 Factors referring to an injury or disease covered by another Statement of Principles Schedule 1 - Dictionary 1 Definitions 1 Name This is the Statement of Principles concerning cluster headache (Reasonable Hypothesis) (No. 57 of 2018). 2 Commencement This instrument commences on 23 July 2018. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning cluster headache No. 20 of 2010 (Federal Register of Legislation No. F2010L01036) made under subsection 196B(2) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies. 6 Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 7 Kind of injury, disease or death to which this Statement of Principles relates (1) This Statement of Principles is about cluster headache and death from cluster headache. Meaning of cluster headache (2) For the purposes of this Statement of Principles, cluster headache: (a) means a headache condition in which there are multiple attacks of severe, unilateral headache in the orbital, supraorbital or temporal region, where each headache typically lasts from 15 to 180 minutes. The headache is accompanied by a sense of restlessness or agitation, or at least one of the following autonomic symptoms occurring on the same side as the pain: (i) conjunctival injection or lacrimation; (ii) eyelid oedema; (iii) forehead and facial sweating; (iv) miosis or ptosis; or (v) nasal congestion or rhinorrhoea; and (b) includes episodic cluster headache and chronic cluster headache; and (c) excludes: (i) headache attributable to inflammatory disorders of the head and neck; (ii) headache attributable to structural abnormalities; (iii) headache attributable to systemic disease; (iv) hemicrania continua; (v) migraine; (vi) paroxysmal hemicrania; (vii) short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT); (viii) short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA); (ix) tension-type headache; and (x) trigeminal neuralgia. Note: Headache attacks in cluster headache typically occur at a frequency between one every other day and eight per day. In episodic cluster headache disorder only, cluster headache attacks occur in bouts separated by asymptomatic periods which are free from cluster headache attacks. (3) While cluster headache attracts ICD‑10‑AM code G44.0, in applying this Statement of Principles the meaning of cluster headache is that given in subsection (2). (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. Death from cluster headache (5) For the purposes of this Statement of Principles, cluster headache, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's cluster headache. Note: terminal event is defined in the Schedule 1 – Dictionary. 8 Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that cluster headache and death from cluster 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. Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary. 9 Factors that must exist At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting cluster headache or death from cluster headache with the circumstances of a person's relevant service: (1) having trauma to the skull or face of the affected side within the seven days before the clinical onset of cluster headache; Note: trauma to the skull or face is defined in the Schedule 1 - Dictionary. (2) having concussion or moderate to severe traumatic brain injury before the clinical onset of cluster headache, where cluster headache has developed within the seven days of: (a) injury to the head; or (b) regaining consciousness following the injury to the head; or (c) discontinuing medication that impairs the ability to sense or report headache following the injury to the head; (3) undergoing eye exenteration of the affected side within the two years before the clinical onset of cluster headache; Note: exenteration is defined in the Schedule 1 - Dictionary. (4) having sleep apnoea at the time of the clinical onset of cluster headache; (5) smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of cluster headache; Note: pack-years of cigarettes, or the equivalent thereof in other tobacco products is defined in the Schedule 1 - Dictionary. (6) using intranasal cocaine at least four times per month for the one year before the clinical onset of cluster headache; (7) having sleep apnoea at the time of the clinical worsening of cluster headache; (8) smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of cluster headache; Note: pack-years of cigarettes, or the equivalent thereof in other tobacco products is defined in the Schedule 1 - Dictionary. (9) taking glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate within the 24 hours before the clinical worsening of cluster headache; (10) consuming alcohol within the 24 hours before the clinical worsening of cluster headache; (11) being treated with sildenafil within the 24 hours before the clinical worsening of cluster headache; (12) inability to obtain appropriate clinical management for cluster headache. 10 Relationship to service (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. (2) The factors set out in subsections 9(7) to 9(12) apply only to material contribution to, or aggravation of, cluster headache where the person's cluster headache was suffered or contracted before or during (but did not arise out of) the person's relevant service. 11 Factors referring to an injury or disease covered by another Statement of Principles In this Statement of Principles: (1) if a factor referred to in section 9 applies in relation to a person; and (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; then 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. Schedule 1 - Dictionary Note: See Section 6 1 Definitions In this instrument: cluster headache—see subsection 7(2). exenteration means removal of the entire contents of the orbit of the eye including the eye and extraocular muscles. MRCA means the Military Rehabilitation and Compensation Act 2004. pack-years of cigarettes, or the equivalent thereof in other tobacco products means a calculation of consumption where one pack-year of cigarettes equals 20 tailor-made cigarettes per day for a period of one calendar year, or 7 300 cigarettes. One tailor-made cigarette approximates one gram of tobacco or one gram of cigar or pipe tobacco by weight. One pack-year of tailor-made cigarettes equates to 7.3 kilograms of smoking tobacco by weight. Tobacco products mean cigarettes, pipe tobacco or cigars, smoked alone or in any combination. relevant service means: (a) operational service under the VEA; (b) peacekeeping service under the VEA; (c) hazardous service under the VEA; (d) British nuclear test defence service under the VEA; (e) warlike service under the MRCA; or (f) non-warlike service under the MRCA. Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary. terminal event means the proximate or ultimate cause of death and includes the following: (a) pneumonia; (b) respiratory failure; (c) cardiac arrest; (d) circulatory failure; or (e) cessation of brain function. trauma to the skull or face means an injury to any or all of those areas of the head, resulting in: (a) fracture of the underlying bones; or (b) laceration of the overlying skin; or (c) external bruise at the site of the trauma. VEA means the Veterans' Entitlements Act 1986.