Suspected neurological conditions: recognition and referral

Sudden-onset dizziness with a focal neurological deficit

Evidence showed that sudden-onset dizziness is more likely to indicate a serious neurological condition if it is accompanied by imbalance and a focal abnormality. The committee confirmed that this is in line with their own clinical experience. They noted that these symptoms can also be caused by hypoglycaemia, and that prompt treatment of hypoglycaemia can reduce neurological damage.

Sudden-onset acute vestibular syndrome

The committee acknowledged the difficulty in differentiating between benign peripheral vertigo and the potentially more serious central vertigo that indicates a possible posterior circulation stroke. They agreed that a rapid bedside test would be a valuable addition to practice and could reduce unnecessary scans.

There is evidence showing that the accuracy of the bedside HINTS (head-impulse–nystagmus–test-of-skew) test is broadly similar to that of MRI in identifying people who have had a stroke and ruling out stroke in those who haven't. However, this accuracy is achieved only if the test is carried out by someone who has training and expertise in its use and interpretation. The committee noted that the HINTS test is non-invasive and would avoid the need for scans in people with a negative HINTS examination. To ensure that all people with stroke are identified promptly, the committee agreed that an immediate referral should be made if there is no healthcare professional with training in the HINTS test available.

Sudden-onset dizziness with no imbalance or focal neurological deficit

Evidence showed that dizziness on its own is less likely to indicate a serious neurological condition than dizziness accompanied by other symptoms or signs. The committee confirmed that this is in line with their own clinical experience. They agreed that dizziness is a common and often self-limiting symptom and that this recommendation will help to reduce unnecessary referrals.

Vertigo on head movement

The committee's clinical experience has shown that for many people, positional vertigo is rapidly relieved by a canalith repositioning manoeuvre such as the Epley manoeuvre. The committee agreed that this is a simple, low-risk and effective intervention that can be offered in primary care.

Vestibular migraine

The committee agreed that the diagnostic criteria for vestibular migraine (vertigo associated with migraine) issued by the International Headache Society would be useful to aid recognition of this condition in primary care.

Recurrent dizziness as part of a functional neurological disorder

In the committee's experience, symptoms caused by a functional neurological disorder can mimic symptoms caused by a physical neurological disorder. Dizziness is a common example of such a symptom. The committee thought it important to make a recommendation highlighting this to enable non-specialists to recognise when recurrent dizziness can be managed as part of a functional neurological disorder, rather than a symptom needing referral for neurological investigation.

Dizziness with altered consciousness

The committee noted that epilepsy can sometimes present as recurrent fixed-pattern dizziness associated with alteration of consciousness.

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Facial pain with persistent facial numbness or abnormal neurological signs

The committee agreed that facial pain together with persistent numbness or abnormal neurological signs should be referred urgently for neuroimaging to exclude a possible infiltrative or intracranial mass lesion.

Unilateral facial pain triggered by touching the face (trigeminal neuralgia)

The committee agreed that trigeminal neuralgia can be managed in primary care, following the recommendations in the NICE guideline on neuropathic pain in adults. A lack of response indicates that specialist review of the diagnosis and treatment is needed.

Scalp tenderness or jaw claudication suggestive of temporal arteritis

The committee noted that temporal arteritis can be difficult to diagnose. Left untreated, it can lead to permanent neurological damage, so the committee thought it important that temporal arteritis is always considered as a possible cause of facial pain and headache in older people.

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Sudden-onset unsteady gait

The committee agreed that sudden onset of an unsteady gait could indicate a vascular event such as a stroke, and therefore people with this symptom should be referred urgently, in line with the NICE guideline on stroke and transient ischaemic attack in over 16s.

Rapidly progressive unsteady gait (gait ataxia)

The committee noted that this is an unusual symptom that could indicate a number of underlying conditions, including a brain tumour, an infection or a paraneoplastic presentation of an ovarian, lung or breast cancer. Because of the seriousness of these conditions, the committee agreed that people with this symptom should be referred urgently for specialist investigation.

Gradually progressive unsteady gait (gait ataxia)

The committee agreed that referral is important to identify treatable causes of a gradually progressive unsteady gait. The committee also agreed that it would be useful to highlight simple measures that can be taken while waiting for an appointment in secondary care. Checking and addressing alcohol consumption, gluten sensitivity and thyroid function can aid management of associated conditions and help to inform diagnosis.

Difficulty initiating and coordinating walking (gait apraxia)

The committee agreed that raising awareness of normal pressure hydrocephalus as a possible cause of gait apraxia is important because it is easily overlooked and can sometimes be treated.

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Sudden-onset limb weakness

In the committee's experience, sudden-onset weakness that is restricted to a single limb is sometimes incorrectly attributed to a compression neuropathy or a musculoskeletal cause. They agreed that stroke or transient ischaemic attack should be suspected in all cases of sudden-onset limb or facial weakness.

Rapidly progressive symmetrical limb weakness

The committee agreed that rapidly progressive symmetrical limb weakness can indicate a potentially life-threatening neuromuscular disorder or cervical myelopathy. These disorders can affect the respiratory muscles and cause respiratory failure. Their presenting features can be difficult to recognise in the early stages of the disorder.

Severe low back pain together with other symptoms

The committee agreed that these symptoms can indicate cauda equina syndrome, which is a medical emergency.

Rapidly progressive weakness of a single limb or hemiparesis

The committee agreed that this symptom can indicate potentially serious neurological disease and needs to be assessed urgently.

Slowly progressive limb or neck weakness

The committee agreed that recognition and referral of slowly progressive limb or neck weakness is covered in the NICE guideline on motor neurone disease. If the weakness is accompanied by symptoms such as problems with swallowing or breathing, an urgent referral is needed.

Lower limb claudication symptoms

The committee agreed that lower limb discomfort that comes on after walking and improves with rest (claudication), and that has no vascular cause, might indicate lumbar canal stenosis. If the pain is severe or disabling, a specialist assessment is indicated and this may be carried out by an extended scope practitioner, neurosurgeon or orthopaedic surgeon.

Recurrent limb or facial weakness as part of a functional neurological disorder

The committee noted that recurrent episodes of limb weakness are not uncommon in people with functional neurological disorders. They agreed that in these cases, referral after each episode of limb weakness is not necessary.

The committee agreed that reassuring adults about the nature of the underlying condition will help to allay their concerns and reduce requests for referrals.

Compression neuropathy

In the committee's experience, compression neuropathies can be recognised on the basis of a history of prolonged pressure on the nerve and the pattern of weakness and numbness. They usually resolve spontaneously within 6 weeks, although a splint might be needed for support during recovery. Reducing recurrent pressure or trauma on the affected nerve aids recovery.

Bell's palsy

The committee agreed that uncomplicated Bell's palsy can be diagnosed and managed in primary care. They thought it important that people with this condition know that recovery time can vary and that recovery might not be complete. Referral for specialist treatment can be beneficial for people who develop troublesome symptoms after recovering from Bell's palsy.

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Memory problems in people aged under 50

The committee agreed that, although difficulties with memory are common in people aged under 50, neurodegenerative disorders affecting memory are rare. Brief memory testing and knowledge of common causes of memory difficulties can reassure the clinician that referral is not needed. No evidence on the diagnostic accuracy of different tools for brief memory testing was identified so the committee agreed not to recommend any specific tests.

Memory problems as part of an anxiety disorder or a functional neurological disorder

The committee noted that difficulty concentrating is a common symptom in people with an anxiety disorder or a functional neurological disorder. It often presents as a problem with memory.

Concentration difficulties associated with myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome or fibromyalgia

The committee pointed out that difficulties with memory and concentration are common in myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome or fibromyalgia, and that these symptoms can be managed as part of the management of those conditions.

Progressive memory problems

The committee agreed that the NICE guideline on dementia provides advice on referring adults with progressive memory problems.

Dense amnesia

The committee thought it important to raise awareness of transient global amnesia, which presents as a single episode of dense amnesia with complete recovery and no features of epilepsy, and has a very low recurrence rate. The committee wanted to help non-specialists differentiate this from transient epileptic amnesia, which is recurrent and needs further investigation.

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Dystonia

The committee wanted non-specialists to be aware that cervical dystonia is diagnosed on the basis of clinical features, and that imaging is unnecessary and can delay treatment. They also wanted to raise awareness of the wide range of ways in which dystonia can present, such as only during the performance of certain tasks or in certain parts of the body.

The committee discussed the possible misinterpretation of dystonia affecting neck and foot posture as an orthopaedic problem, leading to unnecessary orthopaedic referrals. They made a specific recommendation for neurological referral to ensure that dystonia caused by an underlying neurodegenerative condition, or by medication, is identified and managed. If the dystonia is idiopathic, treatment can be offered.

Dystonia as a side effect of medications

The committee wanted to point out that dystonia is a side effect of some widely used antipsychotic and antiemetic medicines. It typically occurs within a few days of starting the medicine. In these cases, the prescriber of the medicine should review it.

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Numbness and weakness

The committee agreed that transient unilateral numbness of sudden onset should be managed in line with the NICE guideline on stroke and transient ischaemic attack in over 16s.

The committee emphasised the immediate risk posed by rapidly progressive symmetrical numbness, which might indicate a post-infective polyneuropathy (Guillain–Barré syndrome) or transverse myelitis and can be difficult to recognise in the early stages.

Sensory disturbances

Although the committee agreed that recurrent, brief, fixed-pattern sensory disturbances are not the most common presentation of epilepsy, they thought referral would be important so as not to miss this important diagnosis.

The committee agreed that persistent, distally predominant altered sensation in the limbs in a person with brisk deep tendon reflexes might indicate a lesion in the brain or spinal cord. In a person with depressed reflexes, it is more likely to indicate a neuropathy.

The committee wanted to raise awareness of the possibility of migraine in people with some types of sensory symptoms, and noted that the NICE guideline on headaches in over 12s provides recommendations on recognition and referral for migraine.

The committee also wanted to encourage non-specialists to explore the possibility of peripheral neuropathy as a cause of sensory symptoms before referral. They thought this would help to ensure that people with these symptoms are referred to the correct service, which may be neurological or non-neurological.

Numbness and tingling as part of a functional neurological disorder

The committee noted that transient sensory symptoms are common in people with a functional neurological disorder. They considered that these symptoms might not need neurological assessment.

The committee agreed that people with a functional neurological disorder might benefit from knowing that their symptoms are likely to fluctuate and evolve with time.

Carpal tunnel syndrome

The committee noted that carpal tunnel syndrome is common and many regions have established management pathways that might not involve neurological services.

Numbness, tingling or pain in the outer thigh

The committee agreed that this is a common condition that usually improves with time, and might benefit from weight loss.

Cervical or lumbar radiculopathy

In the committee's experience, cervical and lumbar radiculopathies usually settle spontaneously within a few weeks. However, the committee thought it important to highlight features that might suggest a more serious underlying condition and need further investigation.

Tingling or sensory disturbances on waking from sleep

The committee noted that this symptom is usually caused by compression related to sleeping posture and resolves rapidly without treatment.

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Insomnia

The committee agreed that difficulty sleeping and brief involuntary movements in sleep are common and benign, and do not indicate a neurological problem.

Symptoms that suggest new-onset epileptic seizures

The committee highlighted the substantial risk of sudden unexpected death in epilepsy (SUDEP) in people who have epileptic seizures during sleep. They therefore emphasised the need for prompt investigation for people with this symptom.

Excessive sleepiness and narcolepsy

The committee thought it important that people with excessive sleepiness are offered assessment for sleep apnoea so that they can be referred in line with local policies and pathways for the management of this condition. They agreed that the Epworth score is a well-established measure of sleep apnoea suitable for use by non-specialists.

Although narcolepsy and cataplexy are rare conditions, the committee thought it important to highlight them to raise awareness among non-specialists.

Sleep behaviour disorders

The committee observed that sleep behaviour disorders vary in severity and on rare occasions can endanger life if they cause a person to undertake potentially harmful behaviours while asleep. They agreed that complex and severe sleep behaviour disorders need further assessment, and that the clinical judgement of the non-specialist is the best means of determining whether to offer further assessment to an individual.

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Distorted sense of smell or taste

In the committee's experience, sudden-onset distortion of sense of smell or taste is usually idiopathic. The committee wanted to reassure non-specialists that this symptom is unlikely to indicate a neurological condition.

Smell or taste hallucinations

The committee agreed that brief, repetitive smell or taste hallucinations can be caused by temporal lobe epilepsy. They noted that this symptom is not likely to be associated with a brain tumour.

Loss of sense of smell or taste

The committee noted that loss of sense of smell or taste is a fairly common reason for referral to neurological services, but rarely has a serious neurological cause. They therefore thought that neuroimaging is not usually needed.

The committee agreed that an exception to this is a loss of sense of smell or taste that can't be attributed to a rhinological cause, normal ageing or neurodegenerative disease, and lasts longer than 3 months.

The committee discussed loss of smell or taste after a head injury. They noted that this is common and does not indicate more extensive brain injury. Loss of sense of smell after a head trauma is not treatable and is often permanent.

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Sudden-onset speech or language disturbance

The committee agreed that sudden-onset speech or language disturbance could indicate a vascular event.

Progressive slurred or disrupted speech

The committee noted that slurred or disrupted speech can indicate serious underlying neurological disease, such as motor neurone disease or myasthenia gravis. Although the prognosis in motor neurone disease is not greatly influenced by early diagnosis, it is important to consider other diagnoses such as myasthenia gravis, which is highly treatable.

Dysphonia

The committee agreed that a quiet or wobbly voice (dysphonia) can be a symptom of laryngeal dystonia, which is potentially treatable.

The committee also wanted to raise awareness of dysphonia as a possible presenting symptom of Parkinson's disease.

Word-finding difficulties as part of an anxiety disorder or a functional neurological disorder

The committee agreed that minor word-finding difficulties are a very common presentation in anxiety disorder and functional neurological disorders.

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Tics

The committee agreed that tics are relatively common and, on their own, are benign. Treatment and management options are limited so there is little value in referring to secondary care. The committee noted that tic disorders are often accompanied by anxiety and distress that might be relieved by psychological therapy. If this is not effective and the tics are very severe or socially disabling, the committee thought that neurological referral to explore further treatment options might be beneficial.

Involuntary movements

The committee observed that involuntary movements (such as in chorea) are often mistaken for tics. Unlike tics, involuntary movements cannot be voluntarily suppressed and if they are severe or persistent, might benefit from treatment.

Small, involuntary muscle twitches are usually benign, and are especially common in the calf muscles. If accompanied by weakness, muscle wasting or muscular rigidity (stiffness), they could indicate neuromuscular disease. Otherwise, the committee considered that it is usually sufficient to reassure the person.

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Tremor suggesting Parkinson's disease

The committee observed that a unilateral or predominantly unilateral tremor, especially if more prominent at rest and accompanied by slowness, is particularly suggestive of Parkinson's disease.

Essential tremor

The committee wanted to help non-specialists differentiate essential tremor from parkinsonian tremor. They noted that essential tremor is usually bilateral and does not affect muscle tone or speed of movement. They thought that essential tremor can usually be managed in primary care.

The committee agreed that troublesome head tremor can often be controlled using treatments available in a movement disorder clinic.

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