Updated Guidelines 2024:
NICE updated headache guidelines in June 2024 with revised migraine prevention recommendations. Topiramate and propranolol now 'consider' options alongside amitriptyline. New stroke prevention guidelines published March 2024. Epilepsy guidelines remain current (April 2022).
Neurology Survival Guide for GPs
Brain-friendly learning that won't give you a headache (unless it's a red flag one!)
☕ Tea-Friendly Learning
⏰ For GP Trainees Short on Time
🚩 Red Flag Focused
Date Updated: 1st Dec 2025
Executive Summary: What You'll Master Today
Because you have 47 other things to do before lunch, and that's just the morning list
What This Page Covers:
- • Data-gathering & examination frameworks
- • Diagnostic approaches & investigation pathways
- • Differential diagnosis frameworks
- • Common neurological conditions in primary care
- • Red flags & "do-not-miss" conditions
- • Holistic care & MDT considerations
Quick Facts at a Glance:
1 in 1000
headaches are brain cancers!
5%
of epileptic death happen in the bath. Another 2% from swimming
15%
of strokes are haemorrhagic
30%
strokes superb improvement within 3m with thrombolysis (10% within 24h)
📁 Downloads
path: NEUROLOGY
- basic overview of neurology.ppt
- blackouts.ppt
- dermatomes.jpg
- epilepsy.doc
- headache - a quick tutorial.doc
- headache differentials 1.jpg
- headache differentials 2.jpg
- headache tutorial framework.doc
- headache tutorial framework2.doc
- headache.ppt
- headaches.ppt
- migraine through cases.ppt
- migraine.doc
- neurology tutorial framework.doc
- parkinsons - clinical top tips.pdf
- parkinsons - top tips.pdf
- parkinsons disease - management in primary care.ppt
- parkinsons disease - pharmacological management.ppt
Brainy Bites: Essential Neurology Wisdom
Key Questions for Data Gathering
Headache: "Tell me about the worst headache of your life" - if this one isn't it, probably not SAH
Seizure: Always ask a witness - patients rarely remember their first seizure
Dizziness: "Show me what you mean" - spinning = vertigo, falling = presyncope
Memory: Ask family first - patients with dementia often don't know they have memory problems
Red Flags – What Not to Miss!
Thunderclap headache:
0-10 in 5 minutes = SAH until proven otherwise
FAST positive:
Face, Arms, Speech, Time - call 999 immediately
Fever + neck stiffness:
Meningitis - don't wait for the rash
Papilloedema:
Raised ICP - urgent neurology referral
1. Data-Gathering & Examination Tips
History-Taking Frameworks
Structured approaches for common neurological presentations
Focused Headache History
Essential Questions:
- • Onset: sudden (thunderclap) vs gradual
- • Character: throbbing vs tight band vs stabbing
- • Location: unilateral vs bilateral
- • Associated symptoms: nausea, photophobia, aura
- • Triggers: stress, foods, hormones, sleep
- • Medication overuse: >15 days/month
Red Flag Features:
- • Sudden onset reaching maximum in 5 minutes
- • Fever with headache
- • New neurological deficit
- • Change in personality/cognition
- • Recent head trauma (3 months)
- • Triggered by cough/valsalva/exercise
First Seizure Assessment
Witness Account (Crucial!):
- • What did they see? Describe the movements
- • How long did it last? (Usually overestimated)
- • Any warning signs beforehand?
- • Post-ictal confusion duration
- • Tongue biting, incontinence
- • Any injury during episode?
Provoking Factors:
- • Sleep deprivation (classic trigger)
- • Alcohol withdrawal
- • Flashing lights (photosensitive epilepsy)
- • Recent illness/fever
- • New medications
- • Drug use (cocaine, amphetamines)
Dizziness Approach
Vertigo (Spinning):
- • Room spinning around them
- • Triggered by head movements
- • Nausea and vomiting
- • Hearing loss (Ménière's)
- • Recent viral illness
Presyncope (Fainting):
- • Feeling of impending faint
- • Triggered by standing
- • Palpitations, chest pain
- • Medications (antihypertensives)
- • Dehydration
Central Causes:
- • Sudden onset with focal signs
- • Diplopia, dysarthria
- • Limb weakness/numbness
- • Gait ataxia
- • Posterior circulation TIA/stroke
Weakness & Sensory Change
UMN vs LMN Pattern:
UMN (Upper Motor Neuron):
- • Increased tone (spasticity)
- • Brisk reflexes
- • Extensor plantar response
- • Pyramidal weakness pattern
LMN (Lower Motor Neuron):
- • Reduced tone (flaccidity)
- • Reduced/absent reflexes
- • Muscle wasting
- • Fasciculations
Sensory Patterns:
- Dermatomal: Follows nerve root distribution (radiculopathy)
- Glove & stocking: Peripheral neuropathy (diabetes, alcohol)
- Hemibody: Central lesion (stroke, MS)
- Progression speed: Acute (stroke), subacute (GBS), chronic (neuropathy)
Examination Tips
Practical neurological examination approaches for primary care
🧠 Cranial Nerve Screen
- • Visual fields (confrontation)
- • Pupils (size, reaction, RAPD)
- • Eye movements (H-pattern)
- • Facial symmetry (smile, frown)
- • Speech (dysarthria vs dysphasia)
💪 Motor Examination
- • Tone (passive movement)
- • Power (MRC scale 0-5)
- • Reflexes (biceps, triceps, knee, ankle)
- • Plantar responses
- • Coordination (finger-nose, heel-shin)
👁️ Fundoscopy
- • Papilloedema (raised ICP)
- • Optic disc pallor (MS, optic neuritis)
- • Diabetic/hypertensive changes
- • Essential in headache patients
🚶 Gait Assessment
- • Ataxic (cerebellar, wide-based)
- • Shuffling (Parkinsonian)
- • Spastic (UMN lesion)
- • High-stepping (foot drop)
- • Romberg's test
🧩 Cognitive Assessment
- • MMSE or MoCA screening
- • Attention and concentration
- • Memory (immediate, recent, remote)
- • Language and comprehension
- • Capacity assessment if needed
⚖️ Cerebellar Examination
- • Dysdiadochokinesis
- • Finger-nose test
- • Heel-shin test
- • Nystagmus
- • Speech (scanning dysarthria)
2. Diagnostic Approach & Investigations
Structured Diagnostic Approaches
GP-safe investigation pathways and when to refer urgently
🚨 Acute Headache Algorithm
Red flags present? → Urgent CT/MRI + same-day referral
Thunderclap onset? → 999 call (SAH suspected)
Fever + neck stiffness? → 999 call (meningitis)
No red flags? → Primary headache management
⚡ First Seizure Pathway
Confirm seizure → Witness account essential
Exclude mimics → Syncope, hypoglycaemia, panic
First fit? → Urgent neurology referral (2 weeks)
Age >65? → Same-day assessment (higher risk)
💫 Dizziness Algorithm
Acute vestibular syndrome? → HINTS exam
Central signs? → Urgent stroke pathway
Positional vertigo? → BPPV (Dix-Hallpike test)
Hearing loss? → ENT referral (Ménière's)
🧠 Cognitive Impairment Pathway
Screen → MMSE/MoCA + collateral history
Bloods → B12, folate, TFTs, glucose, LFTs
Rule out reversible → Depression, medications
Refer → Memory clinic (routine unless rapid decline)
Investigations GP Trainees Should Know
Aligned with RCGP curriculum requirements
🩸 Blood Tests
- • FBC, U&E, LFTs, glucose
- • B12, folate, TFTs
- • ESR, CRP (temporal arteritis)
- • Epilepsy drug levels
- • Infection markers
🧠 Neuroimaging
- • CT head (acute presentations)
- • MRI brain (MS, tumours)
- • CT angiogram (SAH, stroke)
- • When to request urgently
- • Contraindications
⚡ Nerve Studies
- • Nerve conduction studies
- • EMG (electromyography)
- • Carpal tunnel syndrome
- • Peripheral neuropathy
- • Motor neurone disease
💉 Lumbar Puncture
- • Suspected meningitis
- • SAH (if CT negative)
- • MS diagnosis
- • Contraindications (raised ICP)
- • When to avoid
When to Refer / Urgent Advice
Clear referral criteria and urgency levels
🚨 999 / Immediate
- • FAST positive (stroke)
- • Thunderclap headache
- • Meningitis signs
- • Status epilepticus
- • Rapidly progressive weakness (GBS)
⚡ Same Day
- • TIA (within 24 hours)
- • First seizure >65 years
- • Acute confusional state
- • Papilloedema
- • New focal neurology
📅 2 Week Wait
- • Suspected brain tumour
- • First seizure <65 years
- • Progressive neurological deficit
- • Unexplained headache pattern change
- • Cognitive decline (rapid)
3. Differential Diagnosis Frameworks
🤕 Headache Differentials
Tension Headache
Bilateral, tight band, stress-related, no nausea
Migraine ± Aura
Unilateral, throbbing, nausea, photophobia, aura
Cluster Headache
Unilateral, severe, lacrimation, nasal congestion
Medication Overuse
>15 days/month analgesic use, rebound headaches
Raised ICP
Morning headache, vomiting, papilloedema
💫 Dizziness Differentials
BPPV
Positional, brief episodes, Dix-Hallpike positive
Vestibular Neuritis
Acute onset, continuous vertigo, no hearing loss
Ménière's Disease
Episodic vertigo, hearing loss, tinnitus, fullness
Presyncope
Feeling faint, cardiac causes, orthostatic
Central Causes
Stroke/TIA, focal signs, sudden onset
💪 Weakness Differentials
UMN Pattern
• Stroke/TIA
• Multiple sclerosis
• Spinal cord lesion
LMN Pattern
• Peripheral neuropathy
• Radiculopathy
• Motor neurone disease
Functional
Non-organic, inconsistent examination
⚡ Seizure-Like Episodes
Epileptic Seizure
Stereotyped, post-ictal confusion, tongue biting
Syncope
Prodrome, pallor, brief/no post-ictal phase
Functional
Eyes closed, prolonged, no injury, gradual onset
Hypoglycaemia
Diabetic, sweating, responds to glucose
4. Common Conditions in Primary Care
Clinical Features:
- • Unilateral throbbing headache
- • Nausea and vomiting
- • Photophobia and phonophobia
- • Aura in 20% (visual, sensory)
- • Duration 4-72 hours
- • Triggers: stress, foods, hormones
Management (NICE 2024):
- • Acute: NSAIDs + antiemetic
- • Triptans if NSAIDs ineffective
- • Prevention: Consider propranolol, topiramate, amitriptyline
- • Avoid medication overuse
- • Lifestyle advice: sleep, stress, triggers
First Seizure Management:
- • Young adults: Often wait for 2nd seizure
- • >65 years: Consider treatment after 1st seizure
- • Higher risk of underlying cause in elderly
- • All new seizures need urgent assessment
- • DVLA notification required
Ongoing Management:
- • Medication titration by GP
- • Elderly: Start low, go slow (half dose)
- • Regular drug level monitoring
- • Seizure diary
- • Annual review with specialist
Acute Recognition (FAST):
- • Face: Facial droop
- • Arms: Arm weakness
- • Speech: Speech problems
- • Time: Time to call 999
- • Thrombolysis window: 4.5 hours
- • Thrombectomy: up to 24 hours
Secondary Prevention:
- • Antiplatelet therapy (aspirin/clopidogrel)
- • Statin therapy
- • Blood pressure control
- • Diabetes management
- • Lifestyle modification
- • Carotid endarterectomy if indicated
Clinical Features (TRAP):
- • Tremor: Rest tremor, pill-rolling
- • Rigidity: Cogwheel rigidity
- • Akinesia: Bradykinesia, reduced movement
- • Postural instability: Falls, shuffling gait
- • Non-motor: Depression, constipation, sleep disorders
Primary Care Role:
- • Early recognition and referral
- • Medication monitoring
- • Managing non-motor symptoms
- • Coordinating MDT care
- • Supporting carers
- • End-of-life planning
Assessment Approach:
- • Collateral history essential
- • Cognitive screening (MMSE/MoCA)
- • Exclude reversible causes
- • Blood tests: B12, folate, TFTs
- • Depression screening
- • Medication review
Management & Support:
- • Memory clinic referral
- • Advance care planning
- • Carer support and respite
- • Safety assessment
- • DVLA notification
- • Social services involvement
5. Red Flags & "Do-Not-Miss" Conditions
Stroke/TIA
- • Sudden focal neurological deficits
- • FAST positive
- • Speech disturbance
- • Visual field defects
- • Limb weakness/numbness
- • Action: 999 call immediately
Meningitis/Encephalitis
- • Fever + headache + neck stiffness
- • Altered mental state
- • Photophobia
- • Rash (don't wait for it!)
- • Seizures
- • Action: 999 call + antibiotics
Subarachnoid Haemorrhage
- • Thunderclap headache (0-10 in 5 mins)
- • "Worst headache of my life"
- • Neck stiffness
- • Vomiting
- • Loss of consciousness
- • Action: 999 call immediately
Raised Intracranial Pressure
- • Papilloedema on fundoscopy
- • Morning headache + vomiting
- • Progressive headache pattern
- • Cognitive decline
- • Bradycardia (late sign)
- • Action: Urgent neurology referral
Guillain-Barré Syndrome
- • Ascending weakness (legs → arms)
- • Reduced/absent reflexes
- • Recent infection (2-4 weeks)
- • Respiratory muscle weakness
- • Autonomic dysfunction
- • Action: Emergency hospital referral
Cauda Equina Syndrome
- • Bilateral leg weakness
- • Saddle anaesthesia
- • Bladder/bowel dysfunction
- • Sexual dysfunction
- • Severe back pain
- • Action: Emergency MRI + surgery
6. Additional Primary Care Considerations
🤝 Holistic & Long-Term Care
Chronic Illness Review
- • Annual medication review
- • Functional assessment
- • Quality of life measures
- • Carer support needs
Functional Disorders
- • Acknowledge symptoms are real
- • Explain positive diagnosis
- • Physiotherapy referral
- • Psychological support
Polypharmacy & Concordance
- • Drug interactions (especially AEDs)
- • Side effect monitoring
- • Adherence support
- • Deprescribing when appropriate
👥 MDT & Community Support
Allied Health Professionals
- • Physiotherapy (mobility, falls prevention)
- • Occupational therapy (ADLs, equipment)
- • Speech & language therapy (dysphagia)
- • Neurorehabilitation services
Social Care Coordination
- • Care package assessment
- • Respite care arrangements
- • Day centre referrals
- • Equipment and adaptations
Driving & DVLA
- • Seizures: 12 months seizure-free
- • Stroke: 1 month if no deficits
- • Dementia: case-by-case assessment
- • Patient responsibility to notify DVLA
🛡️ Safeguarding & Vulnerable Adults
Capacity Assessment
- • Understand information
- • Retain information
- • Use/weigh information
- • Communicate decision
- • Decision-specific capacity
Legal Frameworks
- • Lasting Power of Attorney
- • Court of Protection
- • Mental Capacity Act
- • Best interests decisions
- • Advance directives
Falls Risk Assessment
- • Medication review
- • Environmental hazards
- • Gait and balance
- • Vision assessment
- • Bone health (osteoporosis)
📚 Learning Opportunities for Trainees
Clinical Experience:
- • Case reviews (falls, seizures, headaches)
- • CEPS neurological examinations
- • Joint consultations with specialists
- • Multidisciplinary team meetings
- • Home visits for chronic conditions
Quality Improvement:
- • Audit epilepsy medication monitoring
- • SEA for delayed diagnosis cases
- • Stroke prevention initiatives
- • Dementia-friendly practice development
- • Falls prevention programmes
You've Got This! 💪
Remember: You don't need to be a neurologist to provide excellent neurological care. You just need to know when to worry, when to treat, and when to refer.
Trust your clinical instincts, use the red flag checklists, and remember that most neurological presentations in primary care are benign. When in doubt, seek advice early - your patients will thank you for being thorough rather than sorry.
Now go reward yourself with that well-deserved coffee ☕
Vertigo: The HINTS examination
The HINTS exam- this exam helps to differentiate between peripheral and central cause of vertigo, such as vestibular neuritis vs stroke. It should be done on patients who present within hours or days of on going vertigo and nystagmus.
- Reassuring HINTS exam is – Unidirectional nystagmus, No vertical skew, and abnormal head impulse test. likely vestibular neuritis.
- Worrying HINTS test is – Bidirectional or vertical nystagmus, vertical skew or normal head impulse test. Need imaging to rule out posterior or cerebellar stroke.
Other Top Tips
- EPILEPSY:
- 1st seizure in young people: medication is often only started after a 2nd seizure. In contrast, new-onset epilepsy in older people (>65y) is often treated after just a single seizure. Why? More likely to be an underlying cause – for example, scarring from a stroke. Risk of harm from seizures may be greater – for example, seizure causes fall >> fracture. Also, more likely to live alone – increased risk of sudden unexpected death in epilepsy (SUDEP).
- All older people with a seizure need to be seen urgently at the hospital for a full workup. Immediately if you think there may have been a stroke that triggered this. 2ww if you are concerned there may be an underlying tumour. Neurology outpatients within 2 weeks for all with new onset of seizures.
- Decision to treat is made by the hospital but GPs asked to up-titrate medication. Bear in mind that as a general rule of thumb: the initial dose and rate of titration of antiepileptic medication in older people should be about half of that in younger patients – helps with tolerability.
