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["Baseline assessment: Suspected"]
["neurological conditions: recognition "]
["and referral"]
["NG127"]
[]
["Published: 1 May 2019"]
["Updated: 2 October 2023"]

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["Baseline assessment tool for suspected neurological conditions: recognition and referral (NICE guideline NG127)"]
["This baseline assessment tool can be used to evaluate whether practice is in line with the recommendations in Suspected neurological conditions: recognition and referral.  It can also help to plan activity to meet the recommendations."]
["The tool can be used by individual services or organisations. Alternatively, an assessment completed with the involvement of all relevant services or organisations would help to develop a picture of activity in the local area."]
["It should be used in conjunction with Suspected neurological conditions: recognition and referral (NICE guideline NG127)."]
["In the first instance, consider whether the guideline is relevant and record the conclusion in the box below."]
["Is the guideline relevant?"]
[]
["The data sheet contains the recommendations from the guideline. Information can be entered about current activity relevant to the recommendation, actions needed to meet the recommendation, deadlines and the names of the responsible leads.  Useful documents can be added as hyperlinks."]
["The table can be adapted to include any other local information that is thought to be useful."]
["If it would be helpful to group the recommendations, for example those that are key priorities for implementation or by deadline, use the filter function in the data menu. "]
["Tools and resources to help put the guidance into practice are available on the NICE website. "]
["National Institute for Health and Care Excellence\nLevel 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT; www.nice.org.uk\n\nCopyright\n© NICE 2024. All rights reserved. Subject to Notice of rights.\n"]

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["Baseline assessment tool for suspected neurological conditions: recognition and referral (NICE guideline NG127)"]
[]
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[null,null,null,null,"Number of recommendations met",{"$f":"COUNTIF(F9:F302,\"Yes\")","v":0}]
[null,null,null,null,"Percentage of recommendations met",{"$f":"IF(ISERROR(F4/F3),\"\",F4/F3)","v":""}]
[]
["NICE recommendation","Guideline reference","Year of recommendation","Is the recommendation relevant?","Current activity/evidence","Recommendation met?","Actions needed to implement recommendation","Is there a risk associated with not implementing this recommendation?","Is there a cost or saving?","Deadline","Lead"]
["Recommendations for adults aged over 16"]
["1.1  Blackouts in adults"]
["Refer urgently adults with new-onset blackouts (transient loss of consciousness), accompanied by features that are strongly suggestive of epileptic seizures, for neurological assessment in line with the recommendation for people with suspected epilepsy in the NICE guideline on transient loss of consciousness (‘blackouts’) in over 16s.","1.1.1",2019]
["Do not routinely refer adults with blackouts if there are clear features of vasovagal syncope, even if associated with brief jerking of the limbs. See recommendation 1.1.4.3 on uncomplicated faint in the NICE guideline on transient loss of consciousness (‘blackouts’) in over 16s.","1.1.2",2019]
["1.2  Dizziness and vertigo in adults"]
["Sudden-onset dizziness with a focal neurological deficit"]
["For adults with sudden-onset dizziness and a focal neurological deficit such as vertical or rotatory nystagmus, new-onset unsteadiness or new‑onset deafness:\n•\tif the person has diabetes, check for and treat hypoglycaemia\n•\tif 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.","1.2.1",2019]
["Sudden-onset acute vestibular syndrome"]
["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.","1.2.2",2019]
["For adults with sudden-onset acute vestibular syndrome who have had a HINTS test:\n•\tbe aware that a negative HINTS test makes a diagnosis of stroke very unlikely\n•\trefer immediately for neuroimaging if the HINTS test shows indications of stroke (a normal head impulse test, direction-changing nystagmus or skew deviation).","1.2.3",2019]
["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.","1.2.4",2019]
["Sudden-onset dizziness with no imbalance or focal neurological deficit"]
["Be aware that dizziness in adults with no imbalance or other focal neurological deficit is unlikely to indicate a serious neurological condition.","1.2.5",2019]
["Vertigo on head movement"]
["For adults with transient rotational vertigo on head movement:\n•\tOffer 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. \n•\tIf 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. \n•\tBe aware that BPPV is common after a head injury or labyrinthitis.","1.2.6",2019]
["Vestibular migraine"]
["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.","1.2.7",2019]
["Recurrent dizziness as part of a functional neurological disorder"]
["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.","1.2.8",2019]
["Advise adults with recurrent dizziness and a diagnosed functional neurological disorder that their dizziness will fluctuate and might increase during times of stress.","1.2.9",2019]
["Dizziness with altered consciousness"]
["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.","1.2.10",2019]
["1.3  Facial pain, atraumatic"]
["Facial pain with persistent facial numbness or abnormal neurological signs"]
["Refer adults with facial pain associated with persistent facial numbness or abnormal neurological signs for neuroimaging using a suspected cancer pathway referral.","1.3.1","2019 amended 2023"]
["Unilateral facial pain triggered by touching the face (trigeminal neuralgia)"]
["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.","1.3.2",2019]
["Scalp tenderness or jaw claudication suggestive of temporal arteritis"]
["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.","1.3.3",2019]
["1.4   Gait unsteadiness"]
["Sudden-onset unsteady gait"]
["For recommendations on assessing sudden-onset unsteady gait in adults, see the NICE guideline on stroke and transient ischaemic attack in over 16s.","1.4.1",2019]
["Rapidly progressive unsteady gait (gait ataxia)"]
["Refer adults with rapidly (within days to weeks) progressive unsteady gait (gait ataxia) for neurological assessment using a suspected cancer pathway referral.","1.4.2","2019 amended 2023"]
["Gradually progressive unsteady gait (gait ataxia)"]
["Refer adults with gradually progressive unsteady gait (gait ataxia) for neurological assessment and:\n•\ttake 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\n•\tcheck thyroid function\n•\tcheck for vitamin B12 and folate deficiency\n•\tconsider serological testing for gluten sensitivity as recommended in the NICE guideline on coeliac disease.","1.4.3",2019]
["Difficulty initiating and coordinating walking (gait apraxia)"]
["Refer adults who have difficulty initiating and coordinating walking (gait apraxia) to neurology or an elderly care clinic to exclude normal pressure hydrocephalus.","1.4.4",2019]
["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.","1.4.5",2019]
["1.5  Handwriting difficulties"]
["Refer adults who have sudden-onset difficulty with handwriting that has no obvious musculoskeletal cause for a neurological assessment according to local stroke pathways.","1.5.1",2019]
["Ask adults who have difficulty with handwriting that has no obvious musculoskeletal cause to demonstrate their handwriting and:\n•\tif they have a problem with generating language rather than hand function, refer for neurological assessment\n•\tif their handwriting is small and slow, consider referring for possible Parkinson’s disease\n•\tif their difficulty is specific to the task of handwriting and examination shows no other abnormalities, consider referring for possible focal dystonia.","1.5.2",2019]
["1.6    Headaches in adults"]
["For advice on referral for headaches in adults, see the NICE guideline on headaches in over 12s.",null,2019]
["1.7   Limb or facial weakness in adults"]
["Sudden-onset limb weakness"]
["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.","1.7.1",2019]
["Rapidly progressive symmetrical limb weakness"]
["Refer immediately adults with rapidly (within 4 weeks) progressive symmetrical limb weakness for neurological assessment and assessment of bulbar and respiratory function.","1.7.2",2019]
["Severe low back pain together with other symptoms"]
["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.","1.7.3",2019]
["Rapidly progressive weakness of a single limb or hemiparesis"]
["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. ","1.7.4","2019 amended 2023"]
["Slowly progressive limb or neck weakness"]
["For adults with slowly (within weeks to months) progressive limb or neck weakness:\n•\trefer for an assessment for neuromuscular disorders, in line with the recommendations on recognition and referral in the NICE guideline on motor neurone disease\n•\trefer urgently if there is any evidence of swallowing impairment \n•\trefer immediately if there is breathlessness at rest or when lying flat.","1.7.5",2019]
["Lower limb claudication symptoms"]
["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.","1.7.6",2019]
["Recurrent limb or facial weakness as part of a functional neurological disorder"]
["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.","1.7.7",2019]
["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.","1.7.8",2019]
["Compression neuropathy"]
["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):\n•\trefer to orthotic services for a splint\n•\treview the symptoms after 6 weeks, and refer for neurological assessment if there is no evidence of improvement.\n\nFor adults with features of radiculopathy, see cervical or lumbar radiculopathy. ","1.7.9",2019]
["Advise adults with compression neuropathy to avoid any activity that might lead to further pressure on the affected nerve.","1.7.10",2019]
["Bell's palsy"]
["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.","1.7.11",2019]
["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.","1.7.12",2019]
["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.","1.7.13",2019]
["1.8  Memory failure and cognitive deterioration"]
["Memory problems in adults aged under 50"]
["For adults aged under 50 with memory problems and no other neurological signs:\n•\tdo not routinely refer if brief testing shows memory function to be normal and symptoms are consistent with concentration difficulties\n•\tbe aware that memory problems or concentration difficulties can be caused by:\n-\trecreational, and some prescription, drugs \n-\talcohol\n-\taffective disorders\n-\tstress.\nFor more information, see initial assessment in non-specialist settings in the NICE guideline on dementia. ","1.8.1",2019]
["Memory problems as part of an anxiety disorder or a functional neurological disorder"]
["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.","1.8.2",2019]
["Concentration difficulties associated with myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome or fibromyalgia"]
["Do not routinely refer adults for neurological assessment if they have concentration difficulties associated with myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome or fibromyalgia. ","1.8.3",2019]
["Progressive memory problems"]
["For guidance on referring adults with progressive memory problems, see initial assessment in non-specialist settings in the NICE guideline on dementia.","1.8.4",2019]
["Dense amnesia"]
["Do not routinely refer adults with a single episode of dense amnesia (inability to recall the recent past or form new memories) if:\n•\tthe episode lasts less than 8 hours and\n•\tthere is complete recovery and\n•\tthere 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).\n\nAdvise the person that they have probably had an episode of transient global amnesia and that the recurrence rate is low.","1.8.5",2019]
["Refer adults with recurrent episodes of dense amnesia to have an assessment for epileptic amnesia.","1.8.6",2019]
["1.9   Posture distortion in adults"]
["Dystonia"]
["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.","1.9.1",2019]
["Do not offer cervical imaging to evaluate suspected cervical dystonia in adults.","1.9.2",2019]
["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).","1.9.3",2019]
["Refer adults with suspected dystonia to have an assessment for diagnosis and possible botulinum toxin treatment.","1.9.4",2019]
["Dystonia as a side effect of medications"]
["Be aware that antipsychotic and antiemetic medicines can trigger or exacerbate dystonia in adults.","1.9.5",2019]
["1.10   Sensory symptoms including tingling or numbness in adults"]
["Numbness and weakness"]
["Assess sudden-onset transient unilateral numbness in adults in line with the NICE guideline on stroke and transient ischaemic attack in over 16s.","1.10.1",2019]
["Refer immediately adults with rapidly progressive (within hours to days) symmetrical numbness and weakness or imbalance to have a neurological assessment.","1.10.2",2019]
["Sensory disturbances"]
["Refer urgently adults with recurrent, brief (less than 2 minutes), fixed-pattern disturbances of sensation to have an assessment for epilepsy.","1.10.3",2019]
["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.","1.10.4",2019]
["Suspect migraine with aura in adults who have sensory symptoms that occur with or without headache and:\n•\tare fully reversible and\n•\tdevelop over at least 5 minutes and\n•\tlast between 5 and 60 minutes.\n\nFor recommendations on diagnosing and managing migraine with aura, see the NICE guideline on headaches in over 12s.","1.10.5",2019]
["For adults with persistent, distally predominant ('stocking' or 'glove and stocking') altered sensation in the limbs and depressed deep tendon reflexes:\n•\tbe alert to the possibility of peripheral neuropathy and consider checking:\n-\tvitamin B12 deficiency\n-\tthyroid function\n-\tfor evidence of coeliac disease in line with the NICE guideline on coeliac disease\n-\trenal function\n-\tblood glucose\n-\tESR (erythrocyte sedimentation rate)\n-\talcohol 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\n•\tif no causes of peripheral neuropathy are found, refer for neurological assessment.","1.10.6",2019]
["Numbness and tingling as part of a functional neurological disorder"]
["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.","1.10.7",2019]
["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.","1.10.8",2019]
["Carpal tunnel syndrome"]
["Refer in line with local pathways if symptoms of carpal tunnel syndrome are severe or persistent after initial management.","1.10.9",2019]
["Numbness, tingling or pain in the outer thigh"]
["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.","1.10.10",2019]
["Cervical or lumbar radiculopathy "]
["Do not routinely refer adults with symptoms of cervical radiculopathy that have remained stable for 6 weeks or more unless:\n•\tpain is not controlled with analgesics or\n•\tthe symptoms are disabling or\n•\tone of the following factors is present:\n-\tage under 20\n-\tgait disturbance\n-\tclumsy or weak hands or legs\n-\tbrisk deep tendon reflexes (triceps and lower limbs)\n-\textensor plantar responses\n-\tnew-onset disturbance of bladder or bowel function.","1.10.11",2019]
["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.","1.10.12",2019]
["Tingling or sensory disturbances on waking from sleep"]
["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.","1.10.13",2019]
["1.11  Sleep disorders in adults"]
["Insomnia"]
["Offer advice on sleep hygiene to adults with insomnia.","1.11.1",2019]
["Do not routinely refer adults with insomnia, jerks on falling asleep or isolated brief episodes of sleep paralysis.","1.11.2",2019]
["Symptoms that suggest new-onset epileptic seizures"]
["Refer urgently adults with symptoms suggestive of new-onset epileptic seizures in sleep for neurological assessment in line with the NICE guideline on epilepsies.","1.11.3",2019]
["Excessive sleepiness and narcolepsy"]
["For adults with excessive sleepiness:\n•\tuse the Epworth score together with history of obstructive symptoms in sleep to assess the likelihood of sleep apnoea\n•\trefer in accordance with local policy\n•\tif 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.","1.11.4",2019]
["Refer adults with narcolepsy, with or without cataplexy, for neurological assessment.","1.11.5",2019]
["Sleep behaviour disorders"]
["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.","1.11.6",2019]
["1.12  Smell or taste problems"]
["Distorted sense of smell or taste"]
["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.","1.12.1",2019]
["Smell or taste hallucinations"]
["Refer adults with transient, repetitive smell or taste hallucinations to have a neurological assessment for epilepsy.","1.12.2",2019]
["Loss of sense of smell or taste"]
["Consider neuroimaging for adults with unexplained loss of sense of smell or taste that lasts more than 3 months.","1.12.3",2019]
["Do not routinely refer adults with loss of sense of smell or taste and normal neuroimaging.","1.12.4",2019]
["Do not routinely refer adults who lose their sense of smell or taste immediately after a head injury.","1.12.5",2019]
["1.13  Speech, swallowing and language problems in adults"]
["Sudden-onset speech or language disturbance"]
["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. ","1.13.1 ","Amended July 2019"]
["Progressive slurred or disrupted speech"]
["For adults with progressive slurred or disrupted speech:\n•\trefer for an assessment for neuromuscular disorders, in line with the recommendations on recognition and referral in the NICE guideline on motor neurone disease\n•\trefer urgently if there is any evidence of swallowing impairment \n•\trefer immediately if there is breathlessness at rest or when lying flat. ","1.13.2",2019]
["Dysphonia"]
["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.","1.13.3",2019]
["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.","1.13.4",2019]
["Word-finding difficulties as part of an anxiety disorder or a functional neurological disorder"]
["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.","1.13.5",2019]
["1.14  Tics and involuntary movements in adults"]
["Tics"]
["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.","1.14.1",2019]
["Consider referring adults with a tic disorder for psychological therapy if the disorder distresses them.","1.14.2",2019]
["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:\n•\tthere are not many medicines available to treat a tic disorder\n•\tthe medicines that are available don’t always work well and can have serious side effects.","1.14.3",2019]
["Involuntary movements"]
["Do not routinely refer adults with isolated involuntary movements of the eyelid unless the movements:\n•\tcause involuntary tight eye closure of both eyes (blepharospasm) or\n•\thave persisted for more than 3 months.","1.14.4",2019]
["In adults with involuntary movements of the face, neck, limbs or trunk that cannot be temporarily suppressed by mental concentration:\n•\trefer for neurological assessment or\n•\trefer to neurology or an eye clinic, according to local provision, if the person has involuntary tight eye closure of both eyes (blepharospasm). ","1.14.5",2019]
["Do not routinely refer adults with small involuntary muscular twitches (fasciculations) unless these are associated with muscle wasting and weakness or muscle rigidity.","1.14.6",2019]
["1.15   Tremor in adults"]
["Tremor suggesting Parkinson's disease"]
["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.","1.15.1",2019]
["Essential tremor"]
["Suspect essential tremor in an adult with symmetrical postural tremor and no symptoms of parkinsonism.","1.15.2",2019]
["In adults with suspected essential tremor:\n•\treview regular medication\n•\tcheck thyroid function\n•\tassess 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.\n\nRefer for neurological assessment only if the symptoms are disabling and first-line treatment as specified in the BNF is ineffective or not tolerated.","1.15.3",2019]
["Consider referring adults with troublesome tremor of the head to a movement disorder clinic.","1.15.4",2019]
["1.16   Information and support"]
["Follow the principles in the NICE guidelines on patient experience in adult NHS services and shared decision making in relation to communication (including different formats and languages), information, shared decision making and continuity of care.","1.16.1",2019]
["Advise adults with suspected neurological conditions to:\n•\tcheck the government’s information on driving with medical conditions to find out whether they might have a condition that needs to be notified to the DVLA (Driver and Vehicle Licensing Agency)\n•\tconsider telling their employer, school or college if their symptoms might affect their ability to work or study.","1.16.2",2019]
["Recommendations for children aged under 16"]
["1.17  Attention, concentration and memory problems"]
["Attention, concentration and memory problems related to epilepsy"]
["Refer urgently children who present with discrete episodes of loss of awareness (mid-activity vacant spells) or of attention and concentration difficulty, in line with the NICE guideline on epilepsies.","1.17.1",2019]
["Be aware that medicines commonly used to treat epilepsy in children can adversely affect concentration and memory.","1.17.2",2019]
["Concentration or memory difficulties that interfere with learning or behaviour"]
["Refer children with concentration or memory difficulties that interfere with learning, school progress or behaviour to community paediatric or paediatric neurodevelopmental services for assessment.","1.17.3",2019]
["Be aware that some children with attention and concentration difficulties do not have hyperactivity.","1.17.4",2019]
["1.18  Blackouts and other paroxysmal events"]
["Blackouts and vacant spells"]
["Refer urgently children with new-onset blackouts (transient loss of consciousness) accompanied by seizure markers for neurological assessment, in line with the recommendation for people with suspected epilepsy in the NICE guideline on transient loss of consciousness (‘blackouts’) in over 16s.","1.18.1",2019]
["Refer urgently children with mid-activity vacant spells or behavioural outbursts associated with altered consciousness or amnesia for the events to have a paediatric assessment.","1.18.2",2019]
["Blackouts in children under 12 years"]
["Refer urgently all children aged under 12 years with blackouts for paediatric assessment.","1.18.3",2019]
["Vasovagal syncope"]
["Do not routinely refer children aged over 12 years with blackouts if there are clear features of vasovagal syncope, even if associated with brief jerking of the limbs, in line with recommendation 1.1.4.3 on uncomplicated faint in the NICE guideline on transient loss of consciousness (‘blackouts’) in over 16s.","1.18.4",2019]
["Blackouts, seizures or amnesia after a head injury"]
["For children who have blackouts, seizures or amnesia for events after a head injury, follow the recommendations on pre-hospital assessment, advice and referral to hospital in the NICE guideline on head injury.","1.18.5",2019]
["1.19  Confusion, acute"]
["For children with unexplained acute confusion:\n•\tarrange an emergency transfer to hospital and\n•\tmeasure blood glucose.","1.19.1",2019]
["Be aware that acute confusion in children can be a symptom of meningitis, encephalitis or poisoning. If infection is suspected, follow the recommendations in the NICE guideline on sepsis for identifying people with suspected sepsis and face-to-face assessment of people with suspected sepsis.","1.19.2",2019]
["For children with acute confusion who have a non-blanching rash or other signs or symptoms suggestive of meningococcal septicaemia, follow the recommendations on suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia) in the NICE guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s.\n\nFor other signs and symptoms of meningococcal septicaemia, see bacterial meningitis and meningococcal septicaemia in children and young people – symptoms, signs and initial assessment in the NICE guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s.\n","1.19.3",2019]
["1.20  Dizziness and vertigo in children"]
["Dizziness with no accompanying symptoms or signs"]
["Be aware that isolated dizziness in children is unlikely to be a symptom of a brain tumour if there are no accompanying symptoms or signs.","1.20.1",2019]
["Be aware that dizziness in children is often a symptom of migraine and may be the predominant feature.","1.20.2",2019]
["Dizziness in older children"]
["Be aware that in older children (usually aged over 8 years), dizziness related to change in posture is often caused by postural hypotension.","1.20.3",2019]
["Dizziness caused by middle ear infection or effusion"]
["In children with dizziness, examine the ears for any signs of infection, inflammation or eardrum perforation.","1.20.4",2019]
["Recurrent dizziness"]
["For children with recurrent episodes of dizziness:\n•\tconsider referring for cardiological assessment if there are any factors that might suggest a cardiac cause, such as blackouts (transient loss of consciousness), a family history of cardiomyopathy or unexplained sudden death, or palpitations\n•\tif there are episodes of dizziness with a fixed symptom pattern, be alert to the possibility of epilepsy as the cause and follow the recommendations in the NICE guideline on epilepsies.","1.20.5",2019]
["1.21   Headaches in children"]
["Headaches in children under 12 years"]
["Refer immediately children aged under 12 years with headache for same-day assessment, according to local pathways, if they have any one of the following:\n•\theadache that wakes them at night\n•\theadache that is present on awakening in the morning\n•\theadache that progressively worsens\n•\theadache triggered or aggravated by coughing, sneezing or bending down\n•\theadache with fever and features of meningism\n•\theadache associated with vomiting\n•\theadache associated with ataxia\n•\theadache associated with change in conscious level or pervasive lethargy\n•\theadache occurring within 5 days of a head injury\n•\theadache associated with squint or failure of upward gaze ('sunsetting').","1.21.1",2019]
["Headaches in children under 4 years"]
["Refer urgently all children aged under 4 years with headache for neurological assessment.","1.21.2",2019]
["Recurrent headaches and migraines"]
["Perform or request fundoscopy for all children with recurrent headache and refer urgently for neurological assessment if there are abnormalities.","1.21.3",2019]
["For all children with recurrent headache:\n•\tbe aware that hypertension might be the cause\n•\tmeasure the child's blood pressure and check the measurement against blood pressure reference ranges adjusted for age and height\n•\trefer children if headaches are consistently worsened by upright posture and relieved by lying down.","1.21.4",2019]
["Do not routinely refer children with migraine unless it is affecting their school life, social life or family activities, or they have one of the features listed in recommendation 1.21.1.","1.21.5",2019]
["Be aware that emotional stress is a strong trigger of migraine and chronic, daily headache in children. Ask the child and their parent or carer about specific learning problems, bullying at school and stress in the family.","1.21.6",2019]
["Ask about analgesic use in children with recurrent headache to ensure that medicine use is not excessive and to assess the likelihood of medication overuse headache. See the NICE guideline on headaches in over 12s for more information on medication overuse headache.","1.21.7",2019]
["1.22   Head shape or size abnormalities"]
["Children with dysmorphic features and developmental delay"]
["Refer urgently to paediatric services children with dysmorphic features and developmental delay.","1.22.1",2019]
["Children aged under 4 years"]
["For all children aged under 4 years with suspected abnormal head shape or size:\n•\ttake 3 consecutive measurements of the child's head circumference at the same appointment, using a disposable paper tape measure\n•\tplot the longest of the 3 measurements on a standardised growth chart, corrected for gestational age\n•\tif the child’s head circumference is below the 2nd centile, refer for paediatric assessment.\n\nOffer follow-up measurements if needed, according to clinical judgement and taking the child’s age into account.","1.22.2",2019]
["For children with a head circumference measurement that differs by 2 or more centile lines from a previous measurement on a standardised growth chart (for example, an increase from the 25th to the 75th centile, or a decrease from the 50th to the 9th centile):\n•\trefer to paediatric services for assessment and cranial imaging to exclude progressive hydrocephalus or microcephaly or\n•\trefer immediately to paediatric services if the child also has any of the following signs or symptoms of raised intracranial pressure:\n-\ttense fontanelle\n-\tsixth nerve palsy\n-\tfailure of upward gaze ('sunsetting')\n-\tvomiting\n-\tunsteadiness (ataxia)\n-\theadache.","1.22.3"," Amended July 2019"]
["For children with a head circumference above the 98th centile that has not changed by more than 2 centile lines from the previous measurement on a standardised growth chart, who are developing normally and who have no symptoms of raised intracranial pressure:\n•\tnote the head size of the biological parents, if possible, to check for familial macrocephaly\n•\tif familial macrocephaly is likely, do not routinely refer the child in the absence of any other problem.","1.22.4",2019]
["Babies aged under 1 year with plagiocephaly"]
["For babies aged under 1 year whose head is flattened on one side (plagiocephaly):\n•\tbe aware that positional plagiocephaly (plagiocephaly caused by pressure outside the skull before or after birth) is the most common cause of asymmetric head shape\n•\tmeasure the distance between the outer canthus of the baby's eye and the tragus of their ear on each side\n•\tif the measurements differ, confirm positional plagiocephaly and do not routinely refer if the baby is developing normally\n•\tif the measurements are the same, suspect unilateral premature closure of lambdoid suture and refer to paediatric services.","1.22.5",2019]
["Advise parents or carers of babies with positional plagiocephaly that it is usually caused by the baby sleeping in one position and can be improved by changing the baby's position when they are lying, encouraging the baby to sit up when awake, and giving the baby time on their tummy.","1.22.6",2019]
["1.23  Hypotonia (‘floppiness’)"]
["For babies aged under 1 year with acute-onset hypotonia (floppiness), examine the baby for signs of cardiac failure, enlargement of the liver or kidneys, pyrexia or an altered level of consciousness, and refer immediately to paediatric services.","1.23.1",2019]
["For babies aged under 1 year with hypotonia (floppiness) that has been present for weeks or months:\n•\tif the baby is weak (for example, with feeding and breathing difficulties), refer urgently to paediatric services or\n•\tif the baby is not weak and has no signs of intercurrent illness, consider referring in line with looking for signs of cerebral palsy in the NICE guideline on cerebral palsy under 25s.","1.23.2",2019]
["1.24   Limb or facial weakness in children"]
["Sudden-onset or progressive limb or facial weakness"]
["Refer immediately children with sudden-onset or rapidly progressive (hours to days) limb or facial weakness for neurological assessment.","1.24.1",2019]
["Refer urgently children with progressive limb weakness for neurological assessment.","1.24.2",2019]
["Limb weakness as part of a developmental disorder"]
["Refer children with limb weakness that is part of a developmental disorder to paediatric services, in line with looking for signs of cerebral palsy in the NICE guideline on cerebral palsy under 25s.","1.24.3",2019]
["Boys with limb weakness"]
["For boys with limb weakness, see recommendations 1.25.3 and 1.25.5 on motor development delay and motor development regression in boys.","1.24.4",2019]
["1.25  Motor development delay or regression, and unsteadiness"]
["New-onset gait abnormality"]
["Refer immediately children with new-onset gait abnormality to acute paediatric services.","1.25.1",2019]
["Motor development delay"]
["Refer children to a child development service, and consider referring for physiotherapy or occupational therapy, in line with the recommendations in the NICE guideline on cerebral palsy in under 25s, if they:\n•\tare not sitting unsupported by 8 months (corrected for gestational age) or\n•\tare not walking independently by 15 months (girls) or 18 months (boys) (corrected for gestational age) or\n•\tshow early asymmetry of hand function (hand preference) before 1 year (corrected for gestational age).","1.25.2",2019]
["If the child is a boy, consider measuring creatinine kinase level to exclude Duchenne muscular dystrophy before the boy has had a specialist review.","1.25.3",2019]
["Motor development regression"]
["Refer children with motor development regression to a paediatric neurodevelopmental service or paediatric neurology depending on locally agreed pathways.","1.25.4",2019]
["If the child is a boy, consider measuring creatinine kinase level to exclude Duchenne muscular dystrophy before the boy has had a specialist review.","1.25.5",2019]
["1.26   Posture distortion in children"]
["Children with a recent head or neck trauma"]
["Refer immediately children with abnormal neck posture and a recent head or neck trauma to an emergency department for assessment, and follow recommendations 1.2.9 and 1.2.10 on cervical immobilisation in the NICE guideline on head injury, and recommendation 1.1.4 on spinal immobilisation in the NICE guideline on spinal injury.","1.26.1",2019]
["Children with no recent trauma"]
["In children with abnormal neck posture, check whether painful cervical lymphadenopathy is the cause.","1.26.2",2019]
["Refer children who develop abnormal limb posture that has no apparent musculoskeletal cause for neurological assessment.","1.26.3",2019]
["Be aware that abnormal head tilt in children can be a symptom of posterior fossa tumour.","1.26.4",2019]
["1.27   Sensory symptoms such as tingling or numbness in children"]
["Tingling together with other symptoms"]
["Refer urgently children who have tingling accompanied by other peripheral nervous system symptoms such as weakness, bladder dysfunction or bowel dysfunction for neurological assessment.","1.27.1",2019]
["Be aware that tingling in children may be the first symptom of an acute polyneuropathy (Guillain–Barré syndrome) or other neuro-inflammatory conditions. If the child has features suggesting motor impairment, refer urgently for neurological assessment.","1.27.2",2019]
["Isolated tingling, altered sensation or paraesthesia"]
["Refer children with isolated tingling, altered sensation or paraesthesia for neurological assessment if the symptoms are episodic and are not associated with compression of a nerve. For more information, see the recommendations on diagnosis and investigations in the NICE guideline on epilepsies.","1.27.3",2019]
["Temporary tingling caused by nerve compression or hyperventilation"]
["Do not routinely refer children for neurological assessment of temporary tingling or numbness if there is a clear history of the symptom being triggered by activities known to cause nerve compression, such as carrying a heavy backpack or sitting with crossed legs.","1.27.4",2019]
["Be aware that in children, hyperventilation is a common cause of transient tingling in the limbs.","1.27.5",2019]
["1.28  Sleep disorders in children"]
["Symptoms suggesting possible respiratory failure"]
["Refer urgently children with neuromuscular disorders who have early-morning headaches or new-onset sleep disturbance for a respiratory assessment.","1.28.1",2019]
["Sleep disorders suggesting nocturnal seizures"]
["Refer urgently children who have symptoms suggestive of new-onset epileptic seizures in sleep for neurological assessment.","1.28.2",2019]
["Narcolepsy"]
["Refer children with symptoms suggestive of narcolepsy, with or without cataplexy, for neurological assessment or a sleep clinic assessment according to local pathways.","1.28.3",2019]
["Sleep disorders suggesting sleep apnoea"]
["Refer children with symptoms of sleep apnoea to ear, nose and throat or paediatric respiratory services, as appropriate, and offer advice on weight loss if the child is obese.","1.28.4",2019]
["Night terrors in children aged over 5 years"]
["Refer children aged over 5 years with new-onset night terrors and children with night terrors that persist after age 12.","1.28.5",2019]
["Night terrors and other sleep disturbances in children aged under 5 years"]
["Reassure parents or carers of children aged under 5 years who have night terrors, repetitive movements, sleep talking or sleep walking that these are common in healthy children and rarely indicate a neurological condition.","1.28.6",2019]
["Offer advice on sleep hygiene to parents or carers of children with insomnia, and consider referring to a health visitor if the child is aged under 5 years.","1.28.7",2019]
["Sleep disorders in children with neurodevelopmental disorders or learning disabilities"]
["Consider referring children with sleep disorders associated with neurodevelopmental disorders or learning disabilities to community paediatric services.","1.28.8",2019]
["Sleep disorders as a result of gastro-oesophageal reflux or constipation"]
["Be aware that sleep disorders in children may be a symptom of gastro-oesophageal reflux or constipation. See the recommendations on diagnosing and investigating gastro-oesophageal reflux disease in the NICE guideline on gastro-oesophageal reflux disease in children and young people, and the NICE guideline on constipation in children and young people.","1.28.9",2019]
["1.29   Speech problems in children"]
["New-onset slurred or disrupted speech"]
["Refer urgently children with new-onset slurred or disrupted speech that is not attributable to prescribed medicines, recreational drugs or alcohol for neurological assessment.","1.29.1",2019]
["Problems with speech development in children aged over 2 years"]
["Consider referring children aged over 2 years with abnormal speech development to speech and language services.","1.29.2",2019]
["Be aware that delay or regression in speech and language in children can be a symptom of autism. Follow the recommendations on recognising children and young people with possible autism and referring children and young people to the autism team in the NICE guideline on recognition, referral and diagnosis of autism spectrum disorder in under 19s.","1.29.3",2019]
["1.30  Squint"]
["New-onset squint with loss of fundal (‘red’) reflex"]
["Refer immediately children with new-onset squint that occurs together with loss of fundal (‘red’) reflex in one or both eyes to ophthalmology services. (Also see recommendations on childhood cancers in NICE’s guideline on suspected cancer.)","1.30.1",2019]
["New-onset squint with ataxia, vomiting or headache"]
["Refer immediately children with new-onset squint that occurs together with ataxia, vomiting or headache to acute paediatric services.","1.30.2",2019]
["Paralytic squint"]
["Refer urgently children with paralytic squint for neurological assessment, even in the absence of other signs and symptoms of raised intracranial pressure.","1.30.3",2019]
["Non-paralytic squint"]
["Refer children with non-paralytic squint to ophthalmology services.","1.30.4",2019]
["1.31  Tics and involuntary movements in children"]
["Sudden-onset involuntary movements"]
["Refer immediately children who have sudden-onset chorea, ataxia or dystonia for neurological assessment.","1.31.1",2019]
["Tics"]
["Do not routinely refer children with simple motor tics that are not troublesome to the child.","1.31.2",2019]
["Advise parents or carers of children with a tic disorder to discuss the disorder with the child’s school, emphasising that the tic is an involuntary movement and the child should not be reprimanded for it.","1.31.3",2019]
["Do not offer medicine for motor tics in children without specialist referral and advice (see recommendation 1.31.6).","1.31.4",2019]
["Be aware that tics and stereotypies (repetitive or ritualistic movements such as body rocking) are more common in children with autism or a learning (intellectual) disability.","1.31.5",2019]
["For children with a tic disorder that has a significant impact on their quality of life, consider referring according to local pathways, as follows:\n•\treferral to mental health services if the tic disorder is associated with symptoms of anxiety or obsessive compulsive behaviour\n•\treferral to the neurodevelopmental team if the tic disorder is associated with symptoms suggestive of autism or attention deficit hyperactivity disorder\n•\treferral for neurological assessment if the tic disorder is severe.","1.31.6",2019]
["1.32  Tremor in children"]
["Tremor of sudden onset or with accompanying neurological signs or symptoms"]
["Refer urgently children presenting with tremor for neurological assessment if:\n•\tthey have additional neurological signs or symptoms such as unsteadiness or\n•\tthe onset of the tremor was sudden.","1.32.1",2019]
["Postural tremor"]
["Be aware that isolated postural tremor in children may be a side effect of sodium valproate or a beta-adrenergic agonist.","1.32.2",2019]
["Consider thyroid function tests for children with postural tremor and other symptoms or signs suggestive of thyroid overactivity.","1.32.3",2019]
["Refer children with postural tremor for occupational therapy only if the tremor is affecting activities of daily living such as writing, eating or dressing.","1.32.4",2019]