Suspected neurological conditions: recognition and referral

For adults with sudden-onset dizziness and a focal neurological deficit such as vertical or rotatory nystagmus, new-onset unsteadiness or new‑onset deafness:

• if the person has diabetes, check for and treat hypoglycaemia

• if the person does not have diabetes, or treating hypoglycaemia does not resolve the symptoms, and benign paroxysmal positional vertigo or postural hypotension do not account for the presentation, refer immediately to exclude posterior circulation stroke, in line with the NICE guideline on stroke and transient ischaemic attack in over 16s.

For adults with sudden-onset acute vestibular syndrome (vertigo, nausea or vomiting and gait unsteadiness), a HINTS (head-impulse–nystagmus–test-of-skew) test should be performed if a healthcare professional with training and experience in the use of this test is available.

For adults with sudden-onset acute vestibular syndrome who have had a HINTS test:

• be aware that a negative HINTS test makes a diagnosis of stroke very unlikely

• refer immediately for neuroimaging if the HINTS test shows indications of stroke (a normal head impulse test, direction-changing nystagmus or skew deviation).

Refer immediately adults with sudden-onset acute vestibular syndrome in whom benign paroxysmal positional vertigo or postural hypotension do not account for the presentation, in line with local stroke pathways, if a healthcare professional with training and experience in the use of the HINTS test is not available.

Be aware that dizziness in adults with no imbalance or other focal neurological deficit is unlikely to indicate a serious neurological condition.

For adults with transient rotational vertigo on head movement:

• Offer the Hallpike manoeuvre to check for benign paroxysmal positional vertigo (BPPV) if a healthcare professional trained in its use is available. If there is no healthcare professional trained in the Hallpike manoeuvre available, refer in accordance with local pathways.

• If BPPV is diagnosed, offer a canalith repositioning manoeuvre (such as the Epley manoeuvre) if a healthcare professional trained in its use is available and if the person does not have unstable cervical spine disease. If there is no healthcare professional trained in a canalith repositioning manoeuvre available, or the person has unstable cervical spine disease, refer in accordance with local pathways.

• Be aware that BPPV is common after a head injury or labyrinthitis.

Be alert to the possibility of vestibular migraine (migraine-associated vertigo) in adults who have episodes of dizziness that last between 5 minutes and 72 hours and a history of recurrent headache.

Be aware that, for adults who have been diagnosed with a functional neurological disorder by a specialist, recurrent dizziness might be part of the disorder and the person might not need re‑referral if there are no new neurological signs. New symptoms or signs in adults who have been diagnosed with a functional neurological disorder by a specialist should be assessed as described in the relevant sections of this guideline.

Advise adults with recurrent dizziness and a diagnosed functional neurological disorder that their dizziness will fluctuate and might increase during times of stress.

Refer adults with recurrent fixed-pattern dizziness associated with alteration of consciousness to have an assessment for epilepsy in line with the NICE guideline on epilepsies.

Refer adults with facial pain associated with persistent facial numbness or abnormal neurological signs for neuroimaging using a suspected cancer pathway referral.

Refer adults with unilateral facial pain that is triggered by touching the affected part of the face (trigeminal neuralgia) and is refractory to treatment, in line with the NICE guideline on neuropathic pain in adults.

For adults with scalp tenderness or jaw claudication suggestive of temporal arteritis, consider blood tests and follow local pathways for suspected giant cell (temporal) arteritis. Be aware that a normal ESR (erythrocyte sedimentation rate) does not exclude a diagnosis of giant cell arteritis.

For recommendations on assessing sudden-onset unsteady gait in adults, see the NICE guideline on stroke and transient ischaemic attack in over 16s.

Refer adults with rapidly (within days to weeks) progressive unsteady gait (gait ataxia) for neurological assessment using a suspected cancer pathway referral.

Refer adults with gradually progressive unsteady gait (gait ataxia) for neurological assessment and:

• take an alcohol history and follow the recommendations in the NICE guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence

• check thyroid function

• check for vitamin B12 and folate deficiency

• consider serological testing for gluten sensitivity as recommended in the NICE guideline on coeliac disease.

Refer adults who have difficulty initiating and coordinating walking (gait apraxia) to neurology or an elderly care clinic to exclude normal pressure hydrocephalus.

For adults with unsteadiness of gait who are at risk of falling, follow the recommendations on multifactorial falls risk assessment in the NICE guideline on falls in older people, and consider referring to a falls prevention team.

Be aware that sudden-onset weakness, even in restricted distribution (for example, sudden hand weakness), may be caused by a stroke or transient ischaemic attack. See the NICE guideline on stroke and transient ischaemic attack in over 16s for recommendations on assessing sudden-onset limb or facial weakness in adults.

Refer immediately adults with rapidly (within 4 weeks) progressive symmetrical limb weakness for neurological assessment and assessment of bulbar and respiratory function.

Refer immediately, in line with local pathways, adults who have severe low back pain radiating into the leg and new-onset disturbance of bladder, bowel or sexual function, or new-onset perineal numbness, to have an assessment for cauda equina syndrome.

Refer adults with very rapidly (within hours to days) progressive weakness of a single limb or hemiparesis for investigation, including neuroimaging, using a suspected cancer pathway referral, in line with the recommendation on brain and central nervous system cancers in adults in the NICE guideline on suspected cancer.

For adults with slowly (within weeks to months) progressive limb or neck weakness:

• refer for an assessment for neuromuscular disorders, in line with the recommendations on recognition and referral in the NICE guideline on motor neurone disease

• refer urgently if there is any evidence of swallowing impairment

• refer immediately if there is breathlessness at rest or when lying flat.

Be aware that lower limb claudication symptoms in adults with adequate peripheral circulation might be caused by lumbar canal stenosis and need specialist assessment and imaging.

Be aware that, for adults who have been diagnosed with a functional neurological disorder by a specialist, recurrent limb weakness might be part of the disorder and the person might not need re‑referral if there are no new neurological signs. New symptoms or signs in adults who have been diagnosed with a functional neurological disorder by a specialist should be assessed as described in the relevant sections of this guideline.

Advise adults with limb or facial weakness ascribed to a functional neurological disorder that their limb or facial weakness might fluctuate and evolve over time and might increase during times of stress.

For adults with clear features of compression neuropathy of the radial nerve, common peroneal nerve or ulnar nerve and no features of a nerve root lesion (radiculopathy):

• refer to orthotic services for a splint

• review the symptoms after 6 weeks, and refer for neurological assessment if there is no evidence of improvement.
  
  For adults with features of radiculopathy, see the section on cervical or lumbar radiculopathy.

Advise adults with compression neuropathy to avoid any activity that might lead to further pressure on the affected nerve.

Do not routinely refer adults with an uncomplicated episode of Bell's palsy (unilateral lower motor neurone pattern facial weakness affecting all parts of the face and including weakness of eye closure) and no evidence of another medical condition such as middle ear disease.

Advise adults with Bell's palsy about eye care, and explain that Bell's palsy improves at different rates and maximum recovery can take several months.

Consider referring adults with Bell's palsy who have developed symptoms of aberrant reinnervation (including gustatory sweating or jaw-winking) 5 months or more after the onset of Bell's palsy for neurological assessment and possible treatment.

For adults aged under 50 with memory problems and no other neurological signs:

• do not routinely refer if brief testing shows memory function to be normal and symptoms are consistent with concentration difficulties

• be aware that memory problems or concentration difficulties can be caused by:

  • recreational, and some prescription, drugs

  • alcohol

  • affective disorders

  • stress.
    
    For more information, see initial assessment in non-specialist settings in the NICE guideline on dementia.

Be aware that, for adults who have an anxiety disorder or have been diagnosed with a functional neurological disorder by a specialist, memory problems and concentration difficulties might be part of the disorder and the person might not need re‑referral if there are no new neurological signs. New symptoms or signs in adults who have been diagnosed with a functional neurological disorder by a specialist should be assessed as described in the relevant sections of this guideline.

Do not routinely refer adults for neurological assessment if they have concentration difficulties associated with myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome or fibromyalgia.

For guidance on referring adults with progressive memory problems, see initial assessment in non-specialist settings in the NICE guideline on dementia.

Do not routinely refer adults with a single episode of dense amnesia (inability to recall the recent past or form new memories) if:

• the episode lasts less than 8 hours and

• there is complete recovery and

• there are no features suggestive of an epileptic seizure (see seizure markers for suspected epilepsy in the NICE guideline on transient loss of consciousness ['blackouts'] in over 16s).
  
  Advise the person that they have probably had an episode of transient global amnesia and that the recurrence rate is low.

Refer adults with recurrent episodes of dense amnesia to have an assessment for epileptic amnesia.

Suspect cervical dystonia in adults who have persistent abnormalities of head or neck posture, with or without head tremor, especially if the symptom improves when the person touches their chin with their hand.

Do not offer cervical imaging to evaluate suspected cervical dystonia in adults.

Be aware that dystonia in adults can affect other parts of the body (for example, it can cause writer's cramp or in‑turned posture of the foot).

Refer adults with suspected dystonia to have an assessment for diagnosis and possible botulinum toxin treatment.

Be aware that antipsychotic and antiemetic medicines can trigger or exacerbate dystonia in adults.

Assess sudden-onset transient unilateral numbness in adults in line with the NICE guideline on stroke and transient ischaemic attack in over 16s.

Refer immediately adults with rapidly progressive (within hours to days) symmetrical numbness and weakness or imbalance to have a neurological assessment.

Refer urgently adults with recurrent, brief (less than 2 minutes), fixed-pattern disturbances of sensation to have an assessment for epilepsy.

Refer adults with persistent, distally predominant altered sensation in the limbs, and brisk deep tendon reflexes, to have an assessment for possible brain or spine disease.

Suspect migraine with aura in adults who have sensory symptoms that occur with or without headache and:

• are fully reversible and

• develop over at least 5 minutes and

• last between 5 and 60 minutes.
  
  For recommendations on diagnosing and managing migraine with aura, see the NICE guideline on headaches in over 12s.

For adults with persistent, distally predominant ('stocking' or 'glove and stocking') altered sensation in the limbs and depressed deep tendon reflexes:

• be alert to the possibility of peripheral neuropathy and consider checking:

  • vitamin B12 deficiency

  • thyroid function

  • for evidence of coeliac disease in line with the NICE guideline on coeliac disease

  • renal function

  • blood glucose

  • ESR (erythrocyte sedimentation rate)

  • alcohol consumption, using a tool such as AUDIT (Alcohol Use Disorders Identification Test), in line with the NICE guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence

• if no causes of peripheral neuropathy are found, refer for neurological assessment.

Be aware that, for adults who have been diagnosed with a functional neurological disorder by a specialist, recurrent numbness and tingling might be part of the disorder and the person might not need re‑referral if there are no new neurological signs. New symptoms or signs in adults who have been diagnosed with a functional neurological disorder by a specialist should be assessed as described in the relevant sections of this guideline.

Advise adults with tingling and a diagnosis of functional neurological disorder that the tingling might fluctuate and evolve over time and could increase at times of stress.

Refer in line with local pathways if symptoms of carpal tunnel syndrome are severe or persistent after initial management.

Reassure adults with unilateral or bilateral numbness, tingling or pain in the distribution of the lateral cutaneous nerve of the thigh (meralgia paraesthetica) that the condition is benign and might improve spontaneously. Consider referring for pain management only if the symptoms are severe.

Do not routinely refer adults with symptoms of cervical radiculopathy that have remained stable for 6 weeks or more unless:

• pain is not controlled with analgesics or

• the symptoms are disabling or

• 1 of the following factors is present:

  • age under 20

  • gait disturbance

  • clumsy or weak hands or legs

  • brisk deep tendon reflexes (triceps and lower limbs)

  • extensor plantar responses

  • new-onset disturbance of bladder or bowel function.

Do not routinely refer adults with symptoms of lumbar radiculopathy that have remained stable for 6 weeks or more unless pain is not controlled with analgesics or symptoms are disabling, in line with the NICE guideline on low back pain and sciatica in over 16s.

Do not routinely refer adults with recurrent episodes of tingling or sensory disturbance in the limbs that are present on waking from sleep and last less than 10 minutes.

Offer advice on sleep hygiene to adults with insomnia.

Do not routinely refer adults with insomnia, jerks on falling asleep or isolated brief episodes of sleep paralysis.

Refer urgently adults with symptoms suggestive of new-onset epileptic seizures in sleep for neurological assessment in line with the NICE guideline on epilepsies.

For adults with excessive sleepiness:

• use the Epworth score together with history of obstructive symptoms in sleep to assess the likelihood of sleep apnoea

• refer in accordance with local policy

• if appropriate, offer advice on weight reduction, alcohol consumption and smoking cessation, in line with NICE guidance on obesity, alcohol-use disorders and smoking and tobacco.

Refer adults with narcolepsy, with or without cataplexy, for neurological assessment.

Consider referring adults with persistent symptoms suggestive of sleep behaviour disorders (such as agitated or violent movements that are more complex than a simple jerking motion) for neurological assessment.

Be aware that sudden-onset distortion of sense of smell or taste in adults is rarely associated with structural neurological abnormality and usually resolves within a few months.

Refer adults with transient, repetitive smell or taste hallucinations to have a neurological assessment for epilepsy.

Consider neuroimaging for adults with unexplained loss of sense of smell or taste that lasts more than 3 months.

Do not routinely refer adults with loss of sense of smell or taste and normal neuroimaging.

Do not routinely refer adults who lose their sense of smell or taste immediately after a head injury.

Refer immediately adults with sudden-onset speech or language disturbance to have an assessment for a vascular event, in line with local stroke pathways and following the recommendations in the NICE guideline on stroke and transient ischaemic attack in over 16s. [amended July 2019]

For adults with progressive slurred or disrupted speech:

• refer for an assessment for neuromuscular disorders, in line with the recommendations on recognition and referral in the NICE guideline on motor neurone disease

• refer urgently if there is any evidence of swallowing impairment

• refer immediately if there is breathlessness at rest or when lying flat.

Consider referring adults with isolated and unexplained persistent dysphonia (a quiet, hoarse or wobbly voice) to have an assessment for laryngeal dystonia (involuntary contractions of the vocal cords) if hoarseness caused by structural abnormality or malignancy has been excluded by ear, nose and throat examination.

Be aware that persistent dysphonia in adults may be a presenting symptom of a neurological condition such as Parkinson's disease. For recommendations on the diagnosis and management of Parkinson's disease, see the NICE guideline on Parkinson's disease in adults.

Be aware that anxiety disorder and functional neurological disorders are the most common causes of minor word-finding difficulties in adults, and people with a diagnosis of anxiety disorder or functional neurological disorder made by a specialist might not need a referral.

Do not routinely refer adults with tics (involuntary movements that can be temporarily suppressed at the expense of mounting inner tension) unless the tics are troublesome or accompanied by additional progressive neurological symptoms.

Consider referring adults with a tic disorder for psychological therapy if the disorder distresses them.

Consider referring adults who have completed psychological therapy for a tic disorder to have a neurological assessment if their symptoms are severe and the disorder continues to distress them, but tell the person that:

• there are not many medicines available to treat a tic disorder

• the medicines that are available don't always work well and can have serious side effects.

Do not routinely refer adults with isolated involuntary movements of the eyelid unless the movements:

• cause involuntary tight eye closure of both eyes (blepharospasm) or

• have persisted for more than 3 months.

In adults with involuntary movements of the face, neck, limbs or trunk that cannot be temporarily suppressed by mental concentration:

• refer for neurological assessment or

• refer to neurology or an eye clinic, according to local provision, if the person has involuntary tight eye closure of both eyes (blepharospasm).

Do not routinely refer adults with small involuntary muscular twitches (fasciculations) unless these are associated with muscle wasting and weakness or muscle rigidity.

Refer adults with suspected parkinsonian tremor, other asymmetric tremor, or tremor associated with stiffness, slowness, balance problems or gait disorders for neurological assessment before treatment, in line with the NICE guideline on Parkinson's disease in adults.

Suspect essential tremor in an adult with symmetrical postural tremor and no symptoms of parkinsonism.

In adults with suspected essential tremor:

• review regular medication

• check thyroid function

• assess alcohol consumption using a tool such as AUDIT (Alcohol Use Disorders Identification Test), in line with the NICE guideline on alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.
  
  Refer for neurological assessment only if the symptoms are disabling and first-line treatment as specified in the BNF is ineffective or not tolerated.

Consider referring adults with troublesome tremor of the head to a movement disorder clinic.