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NICE suspected neurological conditions: recognition and referral

“Since yesterday, I just haven’t been able to use my left hand”: immediate referral, stroke pathway.
“I had a panic attack and my fingers went all numb. Do you think I have a problem with my hands?”: likely hyperventilation; in the absence of any other signs, reassure in primary care.
Symptoms such as tingling or weakness are not uncommon but it can sometimes be difficult to ascertain the underlying cause or the urgency with which to refer. Such symptoms can be frustrating for our patients, while the wide differential diagnosis can often make us feel uneasy in the landscape of primary care… (there goes my morning coffee break fading into the dim and distant past...!).

Below I have summarised the NICE guidance on suspected neurological conditions: recognition and referral (NICE 2019, NG127).

This is not designed to be bedtime reading! Rather, an aide memoire for all things neurological (well, nearly!), covering important conditions/presentations and appropriate referral pathways.

This article was updated in November 2023.

Timeframes

NICE outlines the following timeframes:

NICE criteria What this means
Immediate referral Seen by specialist within a few hours or more quickly if necessary (same-day referral)
Urgent referral Seen by specialist within 2 weeks
Refer Routine referral

Throughout the following table, I have given the most appropriate team NICE suggests we should refer to. Depending on local provisions, you may or may not have some of the specific services available – be guided by local pathways.

I have not included the DVLA guidance on each of these conditions as these often change. However, many of these conditions have restrictions around driving, especially while under investigation. It also may be helpful to review the DVLA fitness to drive guidance if considering a diagnosis below (DVLA – assessing fitness to drive: a guide for medical professionals, March 2019).

Suspected neurological conditions IN ADULTS: recognition and referral

WEAKNESS SYMPTOMS (NICE 2019, NG127)
Symptoms Action
Cauda equina Severe low back pain with radiation into the leg and NEW ONSET of any of:
  • Bladder, bowel or sexual dysfunction.

  • Perineal numbness.
    		•  Immediate referral.
    Weakness Sudden-onset weakness, even if in restricted distribution (e.g. hand only). Immediate referral: stroke pathway.
    Rapidly-progressive SYMMETRICAL weakness occurring over <4w may signify:
  • Potentially life-threatening neuromuscular disorder.

  • Cervical myelopathy.

    • Rapidly-progressive symmetrical weakness or numbness occurring within hours/days:
  • Consider Guillain-Barre syndrome or transverse myelitis.
    		•  Immediate referral to neurology.
    (Needs neurological assessment and assessment of bulbar and respiratory function.)
    Rapidly-progressive weakness of SINGLE LIMB/HEMIPAREIS occurring over hours–days. Refer on suspected cancer pathway (for urgent assessment and neuroimaging).
    Slowly-progressive limb or neck weakness occurring over weeks–months.
    These symptoms may indicate a neuromuscular disorder (e.g. motor neurone disease).    		 Refer neurology. Certain symptoms increase the urgency of referral:
  • Immediate referral if breathlessness at rest or when lying flat.

  • Urgent referral if any evidence of swallowing impairment.
    		•
    As part of a functional neurological disorder (diagnosed by a specialist), recurrent limb or facial weakness may be part of the disorder. If no neurological signs, re-referral not required.
  • Manage in primary care.

  • Likely to fluctuate and may increase at times of stress.

    • If new neurological symptoms develop, assess these new symptoms and refer if required.
    Facial weakness that is Bell's palsy Uncomplicated Bell's palsy:
  • Weakness of ALL facial muscles unilaterally, including forehead and eye closure (lower motor neurone pattern) (in stroke, dual UMN innervation of forehead means eyebrows can be raised).

  • No evidence of another medical condition, e.g. middle ear disease.
    • NICE does not comment on the management of Bell's palsy which is not 'uncomplicated'. We would suggest (BMJ 2015;351:h3725, DTB 2013;51:138):

  • Assess for red flags and refer urgently if any present:

    • Potential upper motor neurone facial weakness.
    History of trauma, e.g. base of skull fracture.
    Suggestion of malignancy, e.g. sudden deafness.
    Acute systemic or severe local infections.
    Children with a facial weakness.
  • Check for:

    • Parotid swelling: parotid tumours can compress facial nerve.
    Bilateral/recurrent disease: ?demylinating disorder.
    Vesicles in ear (Ramsay hunt syndrome) due to varicella zoster: add in antivirals.
    Base referral on clinical suspicion; liaise with secondary care if concerned.    		 Manage uncomplicated Bell's palsy in primary care:
  • Offer high-dose steroids if seen within 72h of onset.

  • Advise about eye care: protect cornea with lubrication/eye taping.

    • Recovery can take several months.
    Consider neurological referral if symptoms of aberrant reinnervation (including gustatory sweating or jaw-winking) occurring ≥5m after onset.
    See Bell's palsy article in the online handbook for further information.
    Compression neuropathy If history of compression unclear or evidence of progressive neurological deficit, consider mononeuritis multiplex. Urgent referral.
    Clear features of compression neuropathy of radial, ulnar or common peroneal nerve, and no features of radiculopathy.
  • A neuropathy is deranged function of a specific peripheral nerve.

  • A radiculopathy is irritation/damage to a nerve root as it exits the spinal cord.
    		•  Usually resolve spontaneously within 6w:
  • Orthotic splint may be required during this time, e.g. to aid wrist/food drop.

  • Avoid activities that may compress the affected nerve.

  • Review after 6w.

    • Neurology referral if no response to splint after 6w use.
    Claudication in lower limbs Symptoms/signs of peripheral arterial disease. Manage as per peripheral arterial disease.
    See peripheral arterial disease article in online handbook for further information.
    If normal peripheral circulation, consider lumbar canal stenosis.
    As a reminder, here are the symptoms/signs of lumbar spinal stenosis (BMJ 2016;352:h6234):
  • Pain exacerbated by walking/standing and relieved by sitting/lying down.

  • Unexplained urinary symptoms.

  • Improvement on bending forwards.

  • Bilateral buttock or leg pain.

  • Neurogenic claudication.

  • Priapism associated with walking (very rare).

  • Wide-based gait.

  • Abnormal Romberg test.
    •      		Refer for specialist assessment/imaging.
    TRANSIENT LOSS OF CONSCIOUSNESS (BLACKOUTS) (NICE 2019, NG127)
    Symptoms Actions
    New-onset transient loss of consciousness... ...with features suggestive of epileptic seizure. Urgent referral.
    ...with features of vasovagal syncope (even if brief jerking of limbs). Referral not usually indicated.
    Features suggestive of uncomplicated faint (the 3 Ps) (NICE 2012, CG109):
  • Posture: prolonged standing.

  • Provoking factors: e.g. pain, medical procedure.

  • Prodromal symptoms: e.g. feeling sweaty/hot.
    		•
    DIZZINESS AND VERTIGO (NICE 2019, NG127)
  • Dizziness = subjective sensation of spinning (vertigo) or a more vague sensation of unsteadiness, and sometimes a feeling of light-headedness or presyncope.

  • Dizziness on its own is unlikely to represent significant neurological disease.
    •
    Symptoms Actions
    Sudden-onset dizziness with... ....focal neurological deficit, e.g.:
  • Vertical/rotary nystagmus.

  • New unsteadiness.

  • New deafness.

    • AND not thought to be BPPV/postural hypotension.
  • If diabetic, check for and treat hypoglycaemia (can mimic many neurological symptoms).

  • IMMEDIATE referral to rule out posterior circulation stroke/TIA.
    		•
    ...NO imbalance or focal neurology. Unlikely to be serious underlying neurological condition.
    Episodic dizziness with altered consciousness Recurrent fixed pattern dizziness with altered consciousness. Refer for assessment for epilepsy.
    Sudden-onset vertigo with nausea/vomiting and gait unsteadiness (acute vestibular syndrome) – Do the HINTS (head-impulse-nystagmus-test-of-skew) test if appropriately skilled to do this.
    See useful resources at the end of this article for a video describing the test, but do note that NICE says do the test ONLY IF YOU ARE APPROPRIATELY SKILLED TO DO THIS (and watching a video may not be sufficient training, we fear!):
  • HINTS looks for stroke, and is suggestive of stroke in any of:

    • Direction-changing nystagmus.
    Skew deviation.
    Normal head impulse test.
  • If HINTS is negative: vestibular stroke very unlikely.

    • Unable to do HINTS: if BPPV or postural hypotension unlikely, refer immediately on stroke pathway.
    HINTS is almost as good as MRI at ruling out stroke BUT only if done by professionals who have had training and expertise in its use and interpretations.
    Transient vertigo occurring with head movements BPPV is common after head injury or labyrinthitis. Offer Hallpike's test (if appropriately trained):
  • Hallpike's test positive (suggest BPPV): offer Epley's manoeuvre (provided no unstable cervical spine disease).
    		•
    Vestibular migraine Consider if dizziness lasting 5mins–72h with a history of recurrent migraine.
    If unsure regarding diagnosis, use the diagnostic criteria from the International Headache Society: IHS Classification ICHD-3     		NICE does not offer guidance on management. We would suggest following the NICE guidance on headaches or the SIGN guidance on pharmacological management of migraine. See the headache and migraine articles in the online handbook.
    Recurrent dizziness in someone with a functional neurological disorder – Usually don't need re-referral unless new neurological signs. Explain that it is likely to fluctuate and be worse at times of stress.
    GAIT PROBLEMS, ABNORMAL MOVEMENTS, TICS, TREMORS AND HANDWRITING DIFFICULTIES (NICE 2019, NG127)
    Symptoms Actions
    Unsteady gait (gait ataxia) Sudden onset. Immediate referral: stroke pathway.
    Rapidly progressive (within days to weeks):
  • Uncommon symptom.

  • Can be due to:

    • Multiple sclerosis.
    Brain tumour.
    Infection: herpes zoster, legionella.
    Paraneoplastic presentation of ovarian, lung or breast cancer.     		Refer on suspected cancer pathway (need urgent neurological assessment).
    Gradually progressive. Routine neurology referral. Also:
  • Enquire regarding alcohol use.

  • Check thyroid function, B12 and folate.

  • Consider serological testing for coeliac disease.
    		•
    Difficulty initiating/coordinating walking (gait apraxia) – Refer to neurology or elderly care to exclude normal pressure hydrocephalus.
    Consider referral to falls clinic if having falls.
    See idiopathic normal pressure hydrocephalus article in the online handbook for further information.
    Tics
    (involuntary movements that can be temporarily suppressed, but this causes mounting inner tension)    		 – Refer if:
  • Troublesome symptoms.

  • Accompanied by progressive neurological symptoms.

    • Otherwise, manage in primary care:
  • Consider psychological therapy if distressing.

  • Consider neurology referral if severe/distressing symptoms after psychological input.

    • If we refer, NICE asks us to counsel patients:
  • There are few medications to treat tic disorders.

  • Efficacy is variable.

  • Severe side-effects can occur.
    		•
    Involuntary movements...
    (e.g. chorea, cannot be voluntarily suppressed)    		 ...of the face, neck, limbs or trunk that cannot be suppressed. Refer to neurology.
    ...of the eyelids. Refer if:
  • Lasting >3m.

  • Involuntary tight eye closure of both eyes (blepharospasm).
    		•
    ...small involuntary muscular twitches (fasciculations). Usually benign (common in calf muscles):
  • Reassure and do not refer.

    • Refer if any one of the following present:
  • Muscle wasting.

  • Weakness.

  • Rigidity.

    • (Consider neuromuscular disease.)
    Tremors Suggestive of Parkinson's disease: asymmetrical tremor, or any tremor associated with stiffness, slowness, balance or gait disturbance. Refer to neurology.
    Essential tremor: suspect if symmetrical, bilateral postural tremor and no symptoms of parkinsonism. Manage in primary care:
  • Review regular medications.

  • Check thyroid function.

  • Assess alcohol consumption.

    • Refer to neurology if symptoms disabling and first-line treatment ineffective/not tolerated.
    If troublesome tremor of the head, consider referral to movement disorder clinic.
    See essential tremor article in the online handbook for further information.
    Handwriting difficulties
    (and no obvious musculoskeletal cause)    		 Sudden onset. Immediate referral: stroke pathway.
    Problem generating language rather than hand function.
    Can be due to cognitive deficit/dementia.
    (Ask patient to write.)    		 Refer to neurology.
    Small, slow handwriting.
    (Ask patient to write.)    		 Refer to neurology: consider Parkinson's disease.
    Difficulties specifically with handwriting and nothing else. Consider referral for possible focal dystonia: to neurology or movement disorder clinic.
    DYSTONIAS (NICE 2019, NG127)
  • Uncontrolled, sometimes painful, muscle spasms
    • Symptoms Actions
    Cervical dystonias Suspect if persistent abnormalities in head/neck posture:
  • Symptoms often improve if person touches their chin with their hand.

  • Head tremor may or may not be present.
    		•  Refer anyone with suspected dystonia.
    They may be offered botulinum toxin treatment.
    Do not refer cervical imaging if cervical dystonia suspected.
    Other dystonias Dystonia may affect other parts of the body, e.g. writer's cramp or in-turned posture of the foot. Refer anyone with suspected dystonia.
    They may be offered botulinum toxin treatment.
    Iatrogenic dystonia Antipsychotic and antiemetic medicines can trigger/worsen dystonia; typically occurs within days of starting the medication.
    Tardive dyskinesia/dystonias can occur some time after starting antipsychotic medication.    		 If drug cause suspected: review medications.
    MEMORY PROBLEMS (NICE 2019, NG127)
    Symptoms Actions
    Amnesia Single episode of dense amnesia (inability to recall the recent past/form new memories) and:
  • Lasted fewer than 8h AND

  • Complete recovery AND

  • No features suggestive of epilepsy.

    • (NICE chose 8h as, from its review of the evidence, most attacks last 1–8h).    		 Single episode which meets the criteria described: manage in primary care.
    Advise the person they have probably had an episode of transient global amnesia and risk of recurrence is low.
    Single episode which doesn't meet the criteria described above. Refer neurology.
    Recurrent episodes (lasting <2h each). Urgent neurology referral to assess for epileptic amnesia.
    Memory problems in those <50y with no abnormal neurology Normal memory function on testing, with symptoms consistent with concentration difficulties. Manage in primary care. Consider other causes:
  • Drugs: recreational/prescription.

  • Alcohol.

  • Affective disorders.

  • Stress.
    		•
    Memory problems related to anxiety or a functional neurological disorder (diagnosed by a specialist) – Manage in primary care.
    Memory problems and concentration difficulties may be part of the disorder. If no neurological signs, re-referral not required.
    If new neurological symptoms develop, assess the new symptoms and refer if required.
    Concentration difficulties in association with ME/CFS or fibromyalgia – Manage in primary care.
    Progressive memory problems – Assess for dementia as per the NICE guidance on dementia (NG97, June 2018).
    See dementia article in the online handbook.
    In a younger adult: if progresses to involve multiple domains of cognitive function, consider multiple sclerosis and refer.
    Rarely can represent a serious neurological condition:
  • NICE says seek collateral history and monitor over 1 month. Obviously, if any red flags present, refer earlier.
    		•
    HEADACHES AND FACIAL PAIN (NICE 2019, NG127)
    Symptoms Actions
    Facial pain (atraumatic) With persistent facial numbness or abnormal neurological signs. Refer on suspected cancer pathway (need assessment and neuroimaging to assess for infiltrative/intracranial mass lesion).
    Trigeminal neuralgia: unilateral facial pain triggered by touch. Manage in primary care.
    Refer if refractory to treatment.
    Temporal arteritis:
  • Scalp tenderness or jaw claudication.

  • Always consider in older people with facial pain and headache.
    		•  Consider bloods (inflammatory markers) but be aware that a normal ESR does not exclude giant cell arteritis.
    Treat urgently due to the risks of irreversible damage to eyesight/stroke.
    If diagnosis uncertain, urgent referral for consideration of temporal artery biopsy.
    Follow local pathways for suspected giant cell arteritis.
    Headache – Follow NICE guideline on headaches.
    See headache article in the online handbook which includes headache red flags.
    SENSORY SYMPTOMS AND SMELL/TASTE DISTURBANCE (NICE 2019, NG127)
    Symptoms Actions
    Numbness
  • Sudden-onset transient unilateral numbness.
    		•  Immediate referral to stroke team.
  • Rapidly-progressive (within hours/days) symmetrical numbness, weakness or imbalance:

    • Consider Guillain-Barre syndrome or transverse myelitis.     		Immediate referral to neurology.
    Numbness and tingling As part of a functional neurological disorder (diagnosed by a specialist), recurrent numbness and tingling may be part of the disorder. If no neurological signs, re-referral not required.
  • Manage in primary care.

  • Likely to fluctuate and may increase at times of stress.

    • If new neurological symptoms develop, assess the new symptoms and refer if required.
    Of the outer thigh (meralgia paraesthetica):
  • Symptoms in the distribution of the lateral cutaneous nerve of the thigh.

  • Unilateral or bilateral.

  • May be painful.
    		•  Manage in primary care:
  • Reassure patients the condition is benign and may improve spontaneously.

  • Consider simple analgesia.

  • If overweight, weight loss may help.

    • Consider pain management referral if symptoms severe.
    In the limbs which occur on waking from sleep and:
  • Are recurrent AND

  • Last <10mins.
    		•  Manage in primary care; do not routinely refer.
    Sensory disturbance Recurrent, brief (<2mins) fixed-pattern disturbances in sensation. Urgent referral to neurology for epilepsy assessment.
    Persistent, distally predominant altered sensation in the limbs and brisk deep tendon reflexes. Refer.
    Need assessment for possible brain/spinal disease (e.g. multiple sclerosis, tumour).
    Migraine with aura. Suspect if sensory symptoms occurring with or without headache and:
  • Are fully reversible.

  • Develop over at least 5mins.

  • Last 5–60mins.
    		•  Manage as per the NICE guidance on headaches in over-12s.
    See articles on headache and migraine in the online handbook.
    Persistent, distally predominant altered sensation in the limbs (glove and stocking) and depressed deep tendon reflexes. Assess for underlying causes of peripheral neuropathy:
  • Consider checking B12, thyroid function, coeliac serology, renal function, blood glucose/HbA1c, ESR.

  • Assess alcohol consumption.

    • Refer to neurology if no cause for peripheral neuropathy found.
    Carpal tunnel syndrome – Refer if severe or persistent after initial management.
    See carpal tunnel syndrome article in the online handbook for further information.
    Cervical radiculopathy
    Radiculopathy can be caused by:
  • Compression from a prolapsed intervertebral disc.

  • Degenerative arthritis of the spine.

  • Less frequently, infection, e.g. herpes zoster/Lyme disease.
    		•  If stable symptoms for <6w and no red flags. Manage in primary care.
    If stable symptoms for >6w and either:
  • Pain not controlled with analgesia.

  • Symptoms disabling.
    		•  Refer.
    If stable symptoms for >6w and ANY ONE of the following:
  • Age <20y.

  • Gait disturbance.

  • Clumsy/weak hands or legs.

  • Brisk deep tendon reflexes (triceps/lower limbs).

  • Extensor plantar responses.

  • New-onset disturbance of bladder/bowel function.
    		•  NICE says make an urgent surgical referral BUT urgent is within 2w. We are concerned many of these symptoms warrant immediate referral. We would suggest:
  • Any red flag symptom: immediate referral.

  • Any signs of cervical myelopathy: immediate referral.

  • Be guided by your clinical judgement and, if in doubt, call secondary care to discuss.
    		•
    If stable symptoms persisting >6w and none of the features above. Do not routinely refer.
    Lumbar radiculopathy –
    causes as above    		 If stable symptoms for <6w and no red flags. Manage in primary care.
    Follow the NICE guidance on low back pain (NICE 2016, NG59).
    See the low back pain article in the online handbook.
    If stable symptoms persisting >6w and no red flags. Follow the NICE guidance on low back pain (NICE 2016, NG59).
    See the low back pain article in the online handbook.
    If stable symptoms for >6w and either:
  • Pain not controlled with analgesia.

  • Symptoms disabling.
    		•  Refer.
    Any symptoms/signs of cauda equina
    (see weakness section above).    		 Immediate referral.
    Smell/taste disturbance Transient, repetitive smell/taste hallucinations. Refer to neurology for possible epilepsy.
    Sudden-onset distortion of smell/taste. Rarely associated with structural neurological abnormality.
    Usually resolves within a few months.
    Loss of smell/taste. Consider neuroimaging if lasts >3m AND cannot be attributed to any of:
  • Rhinological cause.

  • Normal ageing.

  • Neurodegenerative disease.

    • Do not routinely refer if neuroimaging normal.
    If occurred immediately after a head injury:
  • Do not routinely refer.

  • Common; does not indicate more extensive brain injury.

  • No treatment and often permanent.
    		•
    SPEECH, SWALLOWING OR LANGUAGE PROBLEMS (NICE 2019, NG127)
    Symptoms Actions
    Speech/language disturbance Sudden onset. Refer immediately: stroke pathway.
    Progressive slurred/disrupted speech May indicate serious underlying neurological condition, e.g. motor neurone disease or myasthenia gravis.
    Important to identify myasthenia gravis as highly treatable.    		 Routine referral, except:
  • Immediate referral if breathlessness at rest or when lying flat.

  • Urgent referral if any evidence of swallowing impairment.
    		•
    Dysphonia Isolated and unexplained persistent dysphonia (a quiet, hoarse or wobbly voice). Examine ear, nose and throat for a structural abnormality/malignancy.
    If examination normal, consider referral to assess for laryngeal dystonia (involuntary contraction of vocal cords).
    Persistent dysphonia can also be due to Parkinson’s disease, motor neurone disease or myasthenia gravis. If suspected: routine neurology referral.
    The NICE guidance on suspected cancer says: consider a suspected cancer pathway referral if ≥45y with persistent unexplained hoarseness (NICE 2015, NG12).
    Word-finding difficulties As part of an anxiety disorder/functional neurological disorder (diagnosed by a specialist):
  • Commonest causes of minor word-finding difficulties.

  • May wax and wane.

  • May coexist with anxiety, fatigue, migraine, tingling, memory and concentration difficulties.
    		•  May not need referral.
    Isolated word-finding difficulties:
  • Rare.

  • Do not fluctuate.

  • Progression of language difficulties to include reading/comprehension.

  • Can be due to dementia.
    		•  NICE does not comment on referral. It does say that with time, an underlying diagnosis, e.g. Alzheimer’s disease or frontotemporal dementia, may become apparent.
    We would suggest that, depending on the suspected underlying cause, a referral may be warranted. Be guided by clinical findings.
    SLEEP DISORDERS (NICE 2019, NG127)
    Symptoms Actions
    Possible new nocturnal epilepsy Sleep symptoms suggestive of new-onset epilepsy.
    Substantial risk of sudden unexpected death in epilepsy (SUDEP) in people who have epileptic seizures during sleep.    		 Urgent referral to neurology/epilepsy services.
    Insomnia Common, benign and does not indicate a neurological problem. Offer sleep hygiene advice.
    Do not routinely refer for:
  • Insomnia.

  • Jerks on falling asleep.

  • Isolated brief episodes of sleep paralysis.
    		•
    Excessive sleepiness/narcolepsy Excessive sleepiness. Assess for obstructive sleep apnoea, including an Epworth score, and make a routine referral.
    If appropriate, advise on:
  • Weight reduction.

  • Alcohol consumption.

  • Smoking cessation.
    		•
    Narcolepsy (daytime sleepiness and sudden attacks of sleep)
    +/-cataplexy (sudden and transient muscle weakness often triggered by a strong emotion).    		 Refer to neurology.
    Sleep behaviour disorder e.g. agitated/violent movements (more complex than simple jerking).
    Rarely can endanger life if potentially harmful behaviour while asleep.    		 Consider referral to neurology if complex/severe.

    Suspected neurological conditions IN CHILDREN (<16 years): recognition and referral

    WEAKNESS SYMPTOMS (NICE 2019, NG127)
    Symptoms Actions
    Limb or facial weakness Sudden-onset or rapidly progressive (hours–days). Immediate referral for neurological assessment.
    Progressive limb weakness. Urgent referral for neurological assessment.
    Limb weakness… …as part of a developmental disorder. Refer for assessment for cerebral palsy.
    …in boys. Consider measuring creatinine kinase to exclude Duchenne muscular dystrophy.
    DIZZINESS AND VERTIGO (NICE 2019, NG127)
  • Dizziness = subjective sensation of spinning (vertigo) or a more vague sensation of unsteadiness, and sometimes a feeling of light-headedness or presyncope.

  • Dizziness on its own is unlikely to represent significant neurological disease.
    •
    Symptoms Actions
    Dizziness with no associated neurology – Manage in primary care:
  • Isolated dizziness is unlikely to be a symptom of a brain tumour.

  • Dizziness in children is often seen in migraine and may be the main symptom.
    		•
    Dizziness in older children (>8y) Dizziness related to posture change is often caused by postural hypotension.
    Postural hypotension may not be present/reproducible in the consulting room.    		 If confirmed diagnosis of postural hypotension, manage in primary care.
    Dizziness caused by middle ear infection/effusion Examine ears for signs of infection, inflammation or bulging/perforated tympanic membrane. Manage the underlying cause.
    If associated with:
  • Blackouts.

  • Palpitations.

  • Exercise.

  • Family history of cardiomyopathy/unexplained sudden death.
    		•  Consider cardiology referral.
    With a fixed symptom pattern. Consider epilepsy and refer to neurology/epilepsy services.
    TRANSIENT LOSS OF CONSCIOUSNESS (BLACKOUTS) (NICE 2019, NG127)
    Symptom Actions
    Blackouts and vacant spells Any blackout in a child <12y. Urgent referral to paediatrics.
    New-onset blackouts with either:
  • Seizures.

  • Symptoms suggestive of epilepsy.
    		•  Urgent referral: neurology/epilepsy services.
    Mid-activity vacant spells (absences)/behavioural outbursts associated with:
  • Altered consciousness OR

  • Amnesia.
    		•  Urgent referral to paediatrics.
    New-onset blackouts associated with any one of:
  • Recurrent dizziness.

  • Palpitations.

  • Exercise.

  • Family history of cardiomyopathy/unexplained sudden death.
    		•  Consider cardiology referral.
    Blackout after a head injury… …associated with:
  • Currently unconscious.

  • A seizure.
    		•  Immediate referral to paediatrics, via 999 ambulance.
    (NICE Head injury guideline NICE 2014, CG176)
    …associated with:
  • History of loss of consciousness but now recovered OR

  • Amnesia.
    		•  Immediate referral to paediatrics.
    (NICE Head injury guideline NICE 2014, CG176)
    …much delayed paroxysmal events (days or weeks later).
    (NICE made no further comment on what it means by this).    		 Urgent referral to neurology.
    Vasovagal syncope – If over 12y:
    Do not refer routinely if there is a clear history of vasovagal syncope (even if associated with brief jerking of limbs).
    ACUTE CONFUSION (NICE 2019, NG127)
    Symptoms Actions
    Unexplained acute confusion Long differential diagnosis, including:
  • Meningitis.

  • Encephalitis.

  • Intracranial haemorrhage.

  • Raised intracranial pressure.

  • Poisoning.
    		•  Immediate referral: 999 ambulance transfer to hospital. Also:
  • Measure blood glucose.

  • If signs of sepsis, follow NICE guidance on sepsis.

  • If non-blanching rash/other signs or symptoms of meningococcal septicaemia, follow the NICE guidance on suspected meningococcal disease.
    		•
    HEADACHES (NICE 2019, NG127)
    Symptoms Actions
    Headaches in the under-4s ANY headache.
    Also consider if:
  • Excessive crying.

  • High-pitched cry.

  • Excessive irritability.

    • …as a child this age may not be able to articulate what is wrong.    		 Urgent referral for neurological assessment.
    (Headache in the under-4s is unusual and there is a high chance of significant intracranial disease).
    Headaches in the under-12s Headache red flags:
  • Wakes them at night.

  • Present on waking in the morning.

  • Progressively worsening.

  • Triggered/aggravated by coughing, sneezing or bending down.

  • Fever and meningism.

  • Associated with vomiting.

  • Associated with ataxia.

  • Altered conscious level or pervasive lethargy.

  • Within 5d of a head injury.

  • Associated with a squint or failure of upwards gaze (sunsetting).
    		•  Immediate referral if any ONE red flag present.
    (Presence of any one of these symptoms may signify significant intracranial pathology, including a brain tumour).
    Recurrent headaches and migraines
    (carry out fundoscopy and blood pressure check for all)     		Abnormal fundoscopy. Urgent referral.
    Raised blood pressure. NICE does not comment on referral. It does say that raised blood pressure may signify:
  • Raised intracranial pressure.

  • Renal disease.

  • Primary hypertension.

    • We would suggest discussing with paediatrics that day.
    If headache consistently worsened by upright posture and relieved by lying down: can signify spontaneous intracranial hypotension. Refer.
    Migraine with no red flags. Manage in primary care:
  • Emotional stress can trigger migraine/headache: enquire about stressors at home/school.

  • Ask about frequency of analgesia use to assess the risk of medication-overuse headache.

  • Consider referral if affecting school, social life/family activities.
    		•
    CHILD DEVELOPMENT (NICE 2019, NG127)
    Symptoms Actions
    Head shape/size abnormalities… …with dysmorphic features and developmental delay:
  • May signify an underlying syndrome involving premature closure of cranial sutures.
    		•  Urgent referral to paediatrics.
    (Urgent as early surgical intervention may be of benefit depending on the underlying condition).
    …babies <1y with plagiocephaly (head flattened on one side).

    Measure the distance between the outer canthus of the eye and the tragus of the ear on each side…    		 If the measurements are the same: refer to paediatrics: suspect unilateral premature closure of the lambdoid suture.
    If the measurements differ and child development normal: do not refer: positional plagiocephaly:
  • Positional plagiocephaly is the commonest cause of asymmetric head shape.

  • Advise parents that positional plagiocephaly is usually related to sleep. Babies should always SLEEP on their back, but when awake:

    • Encourage baby to sit.
    Give baby time on their tummy.
    …in children <4y with suspected abnormal head shape/size:
  • May indicate disorder of brain growth/raised intracranial pressure.

  • Take 3 consecutive measurements of the child’s head circumference at the same appointment.

  • Plot the longest on the growth chart.
    		•  Refer to paediatrics if:
  • Head circumference is <2nd centile.

  • Head circumference measurement differs by 2 or more centile lines compared with previous measurement on growth chart.

    • Immediate referral to paediatrics if head circumference measurement differs by 2 or more centile lines compared with previous measurement on growth chart AND any ONE of (signs/symptoms of raised intracranial pressure):
  • Tense fontanelle.

  • Sixth nerve palsy.

  • Failure of upwards gaze (sunsetting).

  • Vomiting.

  • Unsteadiness (ataxia).

  • Headache.
    		•
    …head circumference >98th centile (and this has not changed by >2 centiles compared with last measurement on growth chart) and:
  • Normal development.

  • No symptoms/signs of raised intracranial pressure.

    • Record the head circumferences of both biological parents.    		 If familial macrocephaly likely, no referral required.
    Hypotonia in babies <1y Acute onset. Immediate referral to paediatrics:
  • Examine for any signs of cardiac failure, enlargement of liver/kidneys, fever or altered level of consciousness.
    		•
    Present for weeks/months. Urgent referral to paediatrics if weakness present (e.g. affecting feeding/breathing).
    Refer (if not weak/no signs of intercurrent illness) to child development services to assess for cerebral palsy.
    Squint New onset with loss of red reflex (one/both eyes). Immediate referral to ophthalmology.
    (May signify a retinoblastoma. Immediate referral as risk of retinoblastoma spreading to the other eye.)
    New onset with ataxia, vomiting or headache. Immediate referral to paediatrics.
    (May indicate raised intracranial pressure.)
    Paralytic squint:
  • Movement of one/both eyes restricted.

  • Can be a sign of intracerebral tumour/inflammation.
    		•  Urgent referral to neurology.
    Non-paralytic squint:
  • Can move both eyes fully in all directions.

  • Normal red reflex.

  • No ataxia, vomiting or headache.
    		•  Refer to ophthalmology.
    Motor developmental delay/regression and unsteadiness New-onset gait abnormality. Can signify:
  • Trauma.

  • Infection.

  • Appendicitis.

  • Hip abnormality.
    		•  Immediate referral to acute paediatric services.
    Motor developmental delay: if any ONE of the following red flags (corrected for gestational age):
  • Not sitting unsupported by 8m.

  • Not walking independently by:

    • 15m (girls).
    18m (boys).
  • Early asymmetry of hand function (hand preference) before 1y.
    		•  Refer to child development services.
    (Also consider referral for physio/OT as required.)
    If a boy, consider measuring creatinine kinase levels to exclude Duchenne muscular dystrophy before specialist review:
  • If the test is negative, Duchenne muscular dystrophy is unlikely.

  • A negative CK result does not rule out Becher muscular dystrophy.

    • We would suggest that, if we have clinical concerns, we are likely to still be referring irrespective of the CK result. What a CK result will help with is referring to the most appropriate team and making a timely diagnosis.
    Motor development regression Refer to paediatric neurodevelopmental services/paediatric neurology.
    If a boy, consider measuring creatinine kinase levels to exclude Duchenne muscular dystrophy as above.
    Speech problems New-onset slurred/disrupted speech not attributable to:
  • Prescribed medications.

  • Recreational drugs/alcohol.
    		•  Urgent referral.
    (May indicate acute/progressive neurological disorder or epilepsy.)
    Problem with speech development in child >2y.
    (Before the age of 2y, development may be within normal limits and speech difficulties can resolve unaided.)    		 Consider referral to speech and language services.
    Consider referral to autism team:
  • Delay/regression in speech/language can be a symptom of autism.
    		•
    ATTENTION, CONCENTRATION AND MEMORY PROBLEMS (NICE 2019, NG127)
    Symptoms Actions
    Attention, concentration or memory difficulties: consider epilepsy if… Discrete episodes of attention/concentration difficulty or of loss of awareness (mid-activity vacant spells). Urgent referral to neurology/epilepsy services.
    If known epilepsy:
  • Medicines commonly used to treat epilepsy in children can negatively impact concentration/memory.

  • Dose adjustment may be required (refer).
    		•
    Concentration or memory difficulties that interfere with learning, school progress or behaviour Some children with attention and concentration difficulties do not have hyperactivity (delayed identification can occur as not disruptive). Routine referral to community paediatrics/paediatric neurodevelopmental services.
    POSTURE DISORDER, ABNORMAL MOVEMENTS, TICS AND TREMORS (NICE 2019, NG127)
    Symptoms Actions
    Abnormal neck posture… …and recent head/neck trauma. Immediate referral to emergency department.
    Immobilise neck and transfer in 999 ambulance.
    …and no recent trauma:
  • Check for painful cervical lymphadenopathy.

  • Assess for musculoskeletal cause.

  • Head tilt in children can be a sign of posterior fossa tumour.
    		•  Urgent referral if no acute cause/musculoskeletal cause.
    Abnormal limb posture – Urgent referral if no acute cause/musculoskeletal cause.
    Involuntary movements Sudden-onset chorea, ataxia or dystonia.
    May be due to:
  • Space-occupying lesion.

  • Metabolic disturbance.

  • Degenerative condition.

  • Para-infectious condition, e.g. rheumatic fever.

  • Drugs.
    		•  Immediate referral for neurological assessment.
    Tremor Sudden onset OR
    With any neurological signs/symptoms (including unsteadiness).    		 Urgent referral.
    (May signify a space-occupying lesion.)
    Postural tremor – Review medications: isolated postural tremor can be caused by sodium valproate or a beta-adrenergic agonist, e.g. salbutamol.
    Consider checking thyroid function (hyperthyroidism).
    Refer to occupational therapy if affecting activities of daily living.
    Tics
    (commoner in children with autism/learning disability)    		 Simple motor tics, non-troublesome. Do not refer.
    Advise parents:
  • Often resolve.

  • A tic is an involuntary movement and child should not be reprimanded for it.

  • To ensure school is aware.

    • Do not offer medication for tics without specialist input.
    Significant impact on quality of life. Consider referral:
  • To neurology if tic disorder severe: drug treatment/habit reversal therapy can be helpful.

  • To mental health services if tic associated with anxiety/obsessive compulsive behaviour.

  • To neurodevelopmental team if symptoms of autism or attention deficit hyperactivity disorder.
    		•
    SENSORY SYMPTOMS (NICE 2019, NG127)
    Symptoms Actions
    Tingling… …with peripheral nervous system symptoms, e.g.:
  • Weakness.

  • Bladder dysfunction.

  • Bowel dysfunction.
    		•  Urgent referral for neurological assessment.
    (May signify spinal cord pathology.)
    We would also suggest immediate referral if any signs of cauda equina.
    …with any motor impairment. Urgent referral for neurological assessment.
    (May signify Guillain-Barre syndrome or other neuro-inflammatory conditions.)
    Isolated tingling, altered sensation or paraesthesia If episodic symptoms and not associated with nerve compression. Refer to neurology/epilepsy services.
    Temporary tingling… …due to nerve compression and clear history of symptoms triggered by activity, e.g. carrying heavy backpack or sitting with crossed legs. Do not refer.
    …due to hyperventilation (common cause of transient tingling in limbs). Do not refer.
    SLEEP DISORDERS (NICE 2019, NG127)
    Symptoms Actions
    Nocturnal seizures Risk factor for sudden unexpected death in epilepsy (SUDEP). Urgent referral to neurology/epilepsy services.
    Early-morning headaches or new-onset sleep disturbance, especially in a child with a neuromuscular disorder May indicate possible respiratory failure. Urgent referral for respiratory assessment.
    BUT a headache which wakes a child from sleep is a red flag for raised intracranial pressure, and this guidance outlines immediate referral for this symptom in the headache section above.
    Narcolepsy Narcolepsy (daytime sleepiness and sudden attacks of sleep). May also present as poor school performance/concentration.
    +/-cataplexy (sudden and transient muscle weakness often triggered by a strong emotion).    		 Refer to neurology/sleep clinic.
    Sleep apnoea Causes depend on age:
  • Babies/young children: gastro-oesophageal reflux, intercurrent infection.

  • Older children: enlarged tonsils/adenoids, obesity.
    		•  Refer to ENT or paediatric respiratory services.
    Offer advice on weight loss if obese.
    Night terrors New onset in children >5y OR night terrors that started before 5y but persist >12y. Refer to neurology/epilepsy services.
    In the <5y: symptoms include:
  • Night terrors.

  • Repetitive movements.

  • Sleep talking/walking.
    		•  Reassure parents:
  • Common in healthy children.

  • Usually resolves as child gets older.

  • Advise regarding sleep hygiene.

  • Consider referral to health visitor.
    		•
    Other associations with sleep disorder Sleep disorders in children with neurodevelopmental disorders/learning disabilities. Consider referral to community paediatrics.
    Sleep disorders associated with gastro-oesophageal reflux/constipation. Treat the underlying cause.
    Suspected neurological conditions:
  • NICE gives clear guidance on what and how urgently we should refer when people of all ages present with neurological symptoms.

  • With time, referral pathways should start to align with these.
    		•
    Useful resources:
    Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge)
  • DVLA – assessing fitness to drive: a guide for medical professionals

    • Videos
  • YouTube – The HINTS exam (user: Peter Johns)
    •

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