Traumatic Brain Injury

Entitlement Eligibility Guideline (EEG)

Date created: 31 March 2025

ICD-11 code: NA07

VAC medical code: 85000 Traumatic brain injury, concussion, post-concussion syndrome/closed head injury

This publication is available upon request in alternate formats.
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Definition

For the purposes of this entitlement eligibility guideline (EEG), the following two conditions are included:

  • mild traumatic brain injury
    • post-concussion syndrome
    • concussion
    • mild head injury.
  • moderate to severe traumatic brain injury
    • moderate traumatic brain injury
    • severe traumatic brain injury
    • moderate or severe head injury.

Note: Entitlement should be granted for a chronic condition only. For Veterans Affairs Canada (VAC) entitlement purposes, traumatic brain injury (TBI), or an equivalent diagnosis, is considered chronic when the condition has been present six months or longer.

Anatomy and physiology

A traumatic brain injury (TBI) is damage to the brain caused by an outside force, which can lead to problems with thinking, movement, or emotions. TBIs can be mild, moderate, or severe, depending on how serious the injury is. They can also be either open (where something pierces the skull) or closed (where there is no break in the skull). TBIs are a type of brain injury that a person can acquire, not something they're born with.

The process of a TBI happens in stages. The first stage, called the primary injury, happens at the moment of impact. This could be from something like a skull fracture or an object that penetrates the skull, or from the brain moving forcefully inside the skull. During this stage, blood vessels may break, and neurons (brain cells) can be torn or damaged. The second stage, known as secondary injury, occurs after the initial impact. This can last from minutes to days, and includes processes that can harm the brain even more, such as swelling and increased pressure inside the skull.

In the military, TBIs have become more common, especially due to accidents during training, car crashes, and sports. A smaller number of TBIs happen during combat, often caused by blasts or objects that penetrate the skull. About 80% of TBIs in the military are mild.

Gender plays an important role in how TBIs affect people. In general, men are more likely to experience a TBI, especially due to high-risk behaviors, and often have milder cases. However, women are at greater risk of having worse outcomes after a TBI. They are more likely to report symptoms like fatigue, nausea, and sleep problems, and tend to experience longer recovery times, possibly due to hormonal differences. Women may also be more vulnerable to TBIs because of physical differences, like weaker neck muscles, which can increase the risk of concussion. Additionally, factors like intimate partner violence, military sexual trauma, and less access to care can worsen outcomes for women.

Mild traumatic brain injury

In this section

Diagnostic standard

Diagnosis

A diagnosis from a qualified physician or nurse practitioner is required. Wherever possible, the diagnosis of a chronic disability related to mild TBI includes a detailed neurologic exam, brain imaging, neurocognitive assessment, and further evaluations to clarify the extent of the TBI and associated deficits.

Diagnostic considerations

Mild TBIs can be hard to diagnose because there are no clear signs on brain scans (neuroimaging), the injury may not show up right away, and symptoms can take time to appear. Healthcare providers usually rely on the person who was injured or a witness to report symptoms right after the injury happens. Brain scans are not needed to diagnose mild TBI. The main use of brain scans is to check for serious injuries, like bleeding or bruising in the brain, which may need surgery or other treatments right away.

In some cases, especially in combat, people may not be assessed right after the injury. In these situations, healthcare providers may have to rely on what the injured person or witnesses say to diagnose a mild TBI. The severity of the injury at first does not always predict how the person will recover. Some people with mild TBIs might have long-term problems even if their injury seemed mild at first.

Diagnostic criteria

Mild TBI may be differentiated from moderate and severe TBI using various diagnostic definitions, therefore for VAC entitlement purposes the diagnosis of mild TBI will be accepted from the treating qualified physician or nurse practitioner.

The most commonly used diagnostic criteria distinctions between mild, moderate and severe brain injury severity are depicted in Table 1 below.

Table 1Footnote 1 details the criteria for assessing the severity of traumatic brain injuries, categorized as mild, moderate, or severe, and also lists the diagnostic criteria. These criteria include the Glasgow Coma Scale, structural imaging, loss of consciousness, changes in consciousness or mental state, and post-traumatic amnesia.

Table 1: Criteria for assessing the severity of traumatic brain injuries
Diagnostic criteria Mild Moderate Severe
Glasgow coma scale 13 to 15 9 to 12 3 to 8
Structural imaging NormalFootnote * Normal or abnormal Normal or abnormal
Loss of consciousness 0 to 30 minutes Greater than 30 minutes, less than 24 hours Greater than 24 hours
Alteration of consciousness/mental state Up to 24 hours Greater than 24 hours Greater than 24 hours
Post-traumatic amnesia 0 to 1 day Greater than 1 day, less than 7 days Greater than 7 days

Table 1 notes:

  • Return to footnote * referrer Most people with mild TBI will have normal brain scans, meaning there won't be any visible damage. Brain scans are not needed to diagnose mild TBI, but if a CT scan or MRI shows injury to the brain, it can confirm the diagnosis. In the past, mild TBI with visible brain damage on a scan was called "complicated" mild TBI.

  • If the patient meets criteria in more than one category, the higher severity level is selected.

The American Congress of Rehabilitation Medicine also provides diagnostic criteria for mild TBI that is acceptable.

Clinic features

The clinical features of mild TBI can vary widely depending on the severity of the injury and the area of the brain affected. Mild TBIs can cause a wide range of physical, cognitive, emotional, and behavioral symptoms. Some of the more common clinical features associated with mild TBI are outlined below.

Physical symptoms may include, but are not limited to:

  • loss of consciousness: briefly or deeply unconscious after the injury
  • headache: persistent or severe headaches after a TBI
  • nausea and vomiting
  • dizziness and balance problems: may have difficulties with balance and coordination
  • sensory problems: changes in vision, hearing, taste, or smell
  • fatigue and sleep disturbances: feeling tired and having difficulty sleeping
  • weakness: loss of strength in certain body parts
  • coordination difficulties: trouble with fine or gross motor skills
  • tremors or seizures: uncontrolled shaking or convulsions may occur in severe cases.

Cognitive symptoms may include, but are not limited to:

  • memory problems: difficulty recalling events or forming new memories
  • attention and concentration issues: struggling to focus or stay attentive on tasks
  • confusion and disorientation: feeling dazed or having trouble understanding surroundings
  • slowed thinking: difficulty processing information and responding slowly.

Emotional and behavioural symptoms may include, but are not limited to:

  • mood swings: fluctuations in emotions, including irritability and frustration
  • anxiety and depression: feelings of worry, fear, or sadness
  • agitation and restlessness
  • impulsivity: acting without thinking, taking risks without considering consequences
  • social and interpersonal problems: difficulty with relationships and social interactions.

Note: Not all individuals with mild TBI will experience all of these symptoms and the severity and duration of symptoms can vary. Some symptoms may not appear immediately after the injury but may develop or worsen in the hours and days following the trauma. For VAC purposes, symptoms should be present within six months of the initial injury.

Recovery from TBIs can be very different for each person, depending on how severe the injury is. Most people with mild TBI recover within 7 to 10 days, but about 10–20% still have symptoms like headaches, vision problems, nausea, irritability, and trouble concentrating. While 80–85% of people fully recover their thinking skills within 12 months, around 15% continue to have symptoms after a year, and 13.5% have lasting problems with memory or thinking. Recovery is usually most noticeable in the first two years, but for moderate to severe TBIs, more than 50% of people face long-term challenges with thinking or daily activities.

There are two main types of mild TBI injuries: non-blast (or blunt) and blast injuries. Blunt injuries are the most common and can happen from accidents, falls, or impacts. Blast injuries are more common in the military and involve shock waves from explosions, like bombs or improvised explosive devices (IEDs).

Women tend to report more symptoms after a mild TBI than men. They may also be more likely to have ongoing problems with thinking or physical symptoms. Research shows that women who are of childbearing age (between puberty and menopause) are more at risk for poor recovery, while women after menopause tend to do better than men of the same age. Women with mild TBI also often report more mental health issues and post-concussion symptoms. Soldiers working in infantry and combat roles, such as breachers and snipers,  are at a higher risk of getting a TBI compared to those in administrative jobs, and TBIs from combat are linked to a higher risk of lasting symptoms.

Entitlement considerations

In this section

Section A: Causes and/or aggravation

For VAC entitlement purposes, the following factors are accepted to cause or aggravate mild TBI, and may be considered along with the evidence to assist in establishing a relationship to service. The factors have been determined based on a review of up-to-date scientific and medical literature, as well as evidence-based medical best practices. Factors other than those listed may be considered, however consultation with a disability consultant or medical advisor is recommended.

The timelines cited below are for guidance purposes. Each case should be adjudicated on the evidence provided and its own merits.

Factors

  1. Experiencing a specified event at the time of clinical onset or aggravation of mild TBI symptoms.

    Specified events include, but are not limited to:

    • the head being struck by an object
    • the head striking an object
    • the brain undergoing an acceleration or deceleration movement without direct external trauma to the head, such as a whiplash injury
    • an explosion or blast.
  2. Experiencing repeated concussive or sub-concussive forces at the time of clinical onset or aggravation of mild TBI symptoms. Examples include breachers forcing entry into a closed area or snipers repeatedly firing powerful weapons.
  3. Experiencing a consecutive mild TBI, defined as receiving a subsequent mild TBI before fully recovering from a previous head injury at the time of clinical onset or aggravation of mild TBI symptoms.
  4. Inability to obtain appropriate clinical management of mild TBI.

Section B: Medical conditions which are to be included in entitlement/assessment

Section B provides a list of diagnosed medical conditions which are considered for VAC purposes to be included in the entitlement and assessment of mild TBI.

  • Post traumatic headaches
  • Post traumatic migraines
  • Non-specific dizziness

Note: Physical or psychological symptoms of mild TBI such as but not limited to changes in mood, anxiety, sleep disturbance, fatigue, cognition, and headaches, are included in the entitlement and assessment of TBI. Where symptoms develop into a separate diagnosed disorder, consequential entitlement may be considered.

Section C: Common medical conditions which may result in whole or in part from mild traumatic brain injury and/or its treatment

Section C is a list of conditions which can be caused or aggravated by mild TBI and/or its treatment. Conditions listed in Section C are not included in the entitlement and assessment of mild TBI. A consequential entitlement decision may be considered where the individual merits and the medical evidence of the case support a consequential relationship.

Conditions other than those listed in Section C may be considered; consultation with a disability consultant or medical advisor is recommended.

  • Sleep disorders, including but not limited to:

  • Clinically significant psychiatric disorders (with evidence of symptom onset within five years of injury).

    Note: For VAC purposes, clinically significant means requiring ongoing treatment and clinical management.

Moderate to severe traumatic brain injury

In this section

Diagnostic standard

Diagnosis

A diagnosis from a qualified physician is required. Wherever possible, the diagnosis of a chronic disability related to moderate to severe TBI may include a detailed neurologic exam, brain imaging, cognitive assessment, and further evaluations to clarify the extent of the TBI and associated deficits.

Diagnostic considerations

Documentation should be as comprehensive as possible. For VAC purposes confirmatory diagnostic imaging results are required for entitlement of moderate to severe TBI.

Diagnostic criteria

Moderate to severe traumatic brain injury (TBI) happens when the brain is damaged by external forces. This can be shown by at least one of the following:

  • loss of consciousness for more than 30 minutes
  • memory loss for more than 24 hours
  • brain damage seen on a brain scan (like an MRI or CT scan)
  • damage to the protective layer around the brain (dura mater)
  • a Glasgow Coma Scale score of less than 13.

To diagnose moderate to severe TBI, there must be a clear cause of injury that led to the brain's function being disrupted. Common causes of moderate to severe TBI include:

  • the brain being hit by an object or force
  • the head striking a hard surface
  • the brain moving suddenly inside the skull without direct impact (like during a whiplash injury)
  • forces from a blast or explosion.

The severity of the injury is often measured by the Glasgow Coma Scale (GCS), which is completed after the injury, once the person has been treated and is no longer sedated. A GCS score of 8 or lower means a severe TBI, while a score of 9 to 12 typically means a moderate TBI.

Clinical features

Moderate to severe TBIs can cause a wide range of symptoms, depending on how bad the injury is and which parts of the brain are affected. Some common symptoms include:

  • Memory and thinking problems: People with moderate to severe TBIs often have trouble remembering things, paying attention, concentrating, and solving problems. They may also find it harder to learn new information and process things more slowly.
  • Mood and behavior changes: After a moderate to severe TBI, people might experience mood swings, irritability, or other changes in their emotions and behavior. These changes can affect their relationships and overall quality of life.
  • Physical problems: People with moderate to severe brain injuries may have long-term problems with coordination, muscle weakness, or balance. They might also have trouble with fine motor skills, like writing or buttoning a shirt. Some may experience permanent changes in their senses, like vision, hearing, taste, or smell. There could also be long-lasting speech or language issues, making it hard to find words, express ideas, or understand what others say or write. Many people with moderate to severe TBIs also deal with ongoing tiredness, low energy, sleep problems, and chronic pain. Seizures can also be a problem for some people long after the injury.

In the military, the most common causes of moderate to severe TBIs include but are not limited to blast injuries, falls, vehicle collisions, injuries from fragments, and other types of trauma.

Postmenopausal women tend to have better recovery outcomes after moderate to severe TBI than men, but women who are pre-menopausal or perimenopausal (before or around menopause) do not. Women also report more severe symptoms after a TBI compared to men.

Service members who work in the army or in combat roles are at a higher risk of getting a TBI because their jobs often involve exposure to more dangerous situations, like blasts, explosions, and physical impacts. In contrast, those in administrative roles are less likely to face these types of hazards, so they generally have a lower risk of experiencing a TBI.

Moderate to severe TBIs are less common than mild TBIs but usually lead to more serious long-term problems. About 20% of people with moderate to severe TBI return to their normal level of functioning, but it can take two years or more for symptoms to improve.

Entitlement considerations

In this section

Section A: Causes and/or aggravation

Section B: Medical conditions which are to be included in entitlement/ assessment

Section C: Common medical conditions which may result in whole or in part from moderate to severe traumatic brain injury and/or its treatment

Section A: Causes and/or aggravation

For VAC entitlement purposes, the following factors are accepted to cause or aggravate moderate to severe TBI, and may be considered along with the evidence to assist in establishing a relationship to service. The factors have been determined based on a review of up-to-date scientific and medical literature, as well as evidence-based medical best practices. Factors other than those listed may be considered, however consultation with a disability consultant or medical advisor is recommended.

The timelines cited below are for guidance purposes. Each case should be adjudicated on the evidence provided and its own merits.

Factors

  1. Experiencing a specified event at the time of the clinical onset of moderate to severe TBI.

    Specified events include, but are not limited to:

    • the head being struck by an object
    • the head striking an object
    • the brain undergoing an acceleration or deceleration movement without direct external trauma to the head, such as a whiplash injury
    • a foreign body penetrating the brain
    • an explosion or blast.
  2. Inability to obtain appropriate clinical management for moderate to severe TBI.

Section B: Medical conditions which are to be included in entitlement/assessment

Section B provides a list of diagnosed medical conditions which are considered for VAC purposes to be included in the entitlement and assessment of moderate to severe TBI.

  • Penetrating head injury
  • Open head injury
  • Headache, including but not limited to:
    • Post-traumatic headache
    • Post-traumatic migraine

Note: Physical or psychological symptoms of moderate to severe TBI such as but not limited to changes in mood, anxiety, sleep disturbance, fatigue, cognition, and headaches, are included in the entitlement and assessment of TBI. Where symptoms develop into a separate diagnosed disorder, consequential entitlement may be considered.

Section C: Common medical conditions which may result in whole or in part from moderate to severe traumatic brain injury and/or its treatment

Section C is a list of conditions which can be caused or aggravated by moderate to severe TBI and/or its treatment. Conditions listed in Section C are not included in the entitlement and assessment of moderate to severe TBI. A consequential entitlement decision may be considered where the individual merits and the medical evidence of the case support a consequential relationship.

Conditions other than those listed in Section C may be considered; consultation with a disability consultant or medical advisor is recommended.

  • Sleep disorders, including but not limited to:

  • Neurocognitive disorders, including but not limited to:
    • major neurocognitive disorder/dementia (with evidence of symptom onset within 15 years of injury)
    • chronic traumatic encephalopathy (CTE)
  • Seizure disorder/post-traumatic epilepsy
  • Benign paroxysmal positional vertigo (BPPV)
  • Sensorineural hearing loss
  • Tinnitus
  • Clinically significant psychiatric disorders (with evidence of symptom onset within five years of injury)

    Note: For VAC purposes, clinically significant means requiring ongoing treatment and clinical management.

Related VAC guidance and policy:

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