Management guide for primary care
The majority of patients with these symptoms don't need to be referred to the neurology services. This page was written with patients in mind, so feel free to share the links with them.
Fatigue
Isolated fatigue is seldom caused by neurological problems. Despite a name that suggest inflammation of the brain and spinal cord Myalgic Encephalomyelitis (ME) is not diagnosed or managed by neurologists; a more accurate term for this would be chronic fatigue syndrome (CFS).
Fatigue commonly complicates other neurological conditions like Parkinson's disease, multiple Sclerosis, myasthenia gravis and migraine, but on its own does not indicate neurological pathology.
We would do all the usual tests: FBC, U+E, LFT, thyroid function, ESR, CRP and vitamin B12 and vitamin D; we might also do CK, immunoglobulin profile and immunofixation.
Insomnia and obstructive sleep apnoea can definitely contribute so we would ask about and advise treatment for those where relevant.
There are some common techniques which can help manage fatigue whether it is occurring on it's own or in the context of other conditions – have a look at the Symptoms Workbook for some simple strategies.
Insomnia
Routine
The sleep-wake cycle is regulated by chemicals released by the brain (hormones) which have the same cycle every day. If you have a random sleep pattern you will end up being jet-lagged; tired during the day, wide awake at
night.
The sleep routine sometimes has to re-established:
- The sleep routine should be established using a ‘wake-up’ time, not a ‘bed-time’. Going to bed early and then lying awake will make the problem worse. Decide when you need to be awake and start from there – for example my ‘wake-up time’ is 6.30am. Yours may be later.
- You may not NEED 8 hours sleep; if you think that you only need 6 then you should start by going to bed 6 hours before your wake up time – so in my case 00.30.
- If you can’t get to sleep you will be very tired the next day – do not nap, this will break up the routine; don’t self medicate with caffeine, this will keep you awake the next night. Be safe, don’t drive if you are too tired.
- At some point the enforced sleep deprivation will mean that you do fall asleep. The most important thing though is to stick to that wake-up time.
- If you are now sleeping better but feel that you need more sleep try making bed-time earlier, but not by too much, try tacking on an extra 20 minutes
Environment
The hormones mentioned above are in part controlled by light and so you can induce jet-lag by exposing yourself to light at the wrong times. People also sleep soundly if they are in a calm, comfortable, familiar environment; if you are uncomfortable your mind will be alert and you won’t sleep well:
- The bedroom should be dark
- The bedroom should be quiet
- The bedroom should be a comfortable temperature
- The bedroom should be calm – no screens, no work stuff, no mess
- Don’t bring problems into the bedroom – no arguments, no discussions about important or stressful issues
Lifestyle
Anxiety and stimulation will wake you up. You need to make sure that you are relaxed and calm before getting into bed.
- No screens or work for an hour before you go to bed
- Do get some physical exercise during the day, but don’t do aerobic exercise in last three hours before bed – this will wake you up (for some reason sex
doesn’t fall into this category, this doesn’t seem to keep people awake)
Diet
A full stomach or bladder or stimulants such as caffeine and sugar will keep you awake; try to reduce intake in the evening.
- No caffeine in the afternoon
- No alcohol – it is a temporary solution and you may wake up with a full bladder
- No nicotine – this is a stimulant
- Not too much sugar – this is a stimulant
- Don’t go to bed straight with a full stomach
Break the cycle of insomnia
Once you are aware that you have problems sleeping this can be a source of anxiety; try to manage this.
- Don’t lie in bed desperately trying to go to sleep. If you are wide-awake for more than 20 minutes get up, go to another room and try to do something relaxing
Darideroxant
This medication has been licensed for use in insomnia. It is green on the Bsol formulary which means that it can be initiated in primary care. It is an orexin analogue, so works to trigger sleep – it does not keep you asleep that is adenosine (the chemical which is blocked by caffeine)
Eligibility Criteria
- Adults with insomnia symptoms lasting ≥3 nights per week for at least 3 months.
- Symptoms must cause considerable impact on daytime functioning.
Only if: - cognitive behavioural therapy for insomnia (CBTi) has been tried but not worked, OR
- CBTi is not available or unsuitable.
Exclusion Criteria
- Significant mental health issues causing the insomnia
Caution
- Cytochrome p450A inhibitors – anti fungals, anti virals, verapamil (blood pressure tablet), clarithromycin or erythromycin (antibiotics)
- Usage
- Use for the shortest time you can in conjunction with the guidelines above
- Review efficacy after 3 months
- Efficacy at >12 months is not known
Brain fog
Lots of people feel that their short-term memory is bad. Common examples of poor short-term memory in this sort of context would include:
- Losing something like your keys, wallet or mobile phone – putting it down and forgetting where.
- Going to another room, floor or even location and then not being able to remember why you are there.
- Losing your train of thought mid-sentence or forgetting a really common word or a word that you use all the time.
- Forgetting the name of someone you know reasonably well.
- Forgetting to do something important, like book annual leave.
- Realising half-way through a TV show or movie that you have seen it before.
- Being told something by a friend or family member and then having no recollection of this later or even the conversation where it came up.
In fact, these sort of lapses are not a failure of short-term memory but of transferring the information from working memory (the last six or seven seconds) into the short-term memory (the last few minutes to hours). This process requires concentration and attention, and it is a problem with these function that is causing the apparent memory lapses.
A easy way to understand this is to think about dialling a phone number. If someone tells you the number, you can retain it long enough to dial it into the phone; this is Working Memory. If you can’t dial it in straight away, you will need to make an effort to retain it until you get to the phone and this requires Concentration and Attention. If those functions aren’t working well enough then the number just evaporates.
So when people complain that seem to forget everything, it is most likely the never committed it to memory in the first place.
In terms of management, the best thing is for patients to employ some of the same strategies as are used in Attention Deficit Hyperactivity Disorder (ADHD).
There are lots of other factors which affect Concentration and Attention and it would be sensible to address these:
- Insomnia and poor sleep, including obstructive sleep apnoea
- Fatigue
- Anxiety or depression or other significant mental illness
- Pain
- Medication, especially pain medication.
If the degree of attention impairment is very high, there is always the possibility the patient has undiagnosed ADHD.
Restless legs
Restless leg syndrome is an unpleasant feeling in one or more limbs which is partially relieved by movement. It is worse when you rest and gets worse as the day wears on. It can be described as pain or tingling and so can be mistaken for neuropathy (nerve damage) or radiculopathy/sciatica (problems arising from the nerve root or sciatic nerve).
Address and reverse any exacerbating factors
- Iron deficiency anaemia, or if serum ferritin is less than 75 micrograms/L.
Investigate to identify a cause of iron deficiency and prescribe iron supplements.
Give Iron supplements until the ferritin is >75micrograms/L and the Iron Saturation
is >20% - Try to avoid stimulants:
- Caffeine
- Alcohol
- Nicotine
- Try to change any problematic drugs:
- Neuroleptics (metoclopramide, olanzapine, etc.)
- Tricyclic anti-depressants (amitriptyline, etc.)
- SSRIs (fluoxetine, etc.)
- SNRIs (venlafaxine, etc.)
- Anti-histamines
Offer self-help advice to all people with RLS. Consider including
- Try to improve sleep quality – see insomnia letter
- Moderate regular exercise.
- Walking and stretching the affected limbs.
- Application of heat with heat pads or a hot bath.
- Relaxation exercises.
- Mental alertness distraction at times of rest (for example, games or reading)
- Massaging affected limbs.
Drug treatment
- First line is an alpha-2-delta ligand – gabapentin, pregabalin.
- Second Line is opioids – codeine 30 to 60mg OD at night; buprenorphine patch 5 to 20 micrograms/hr
- Third line clonazepam – 02.5 to 1.0mg at bed-time.
- Dopamine agonists (e.g., rotigotine, ropinarole) should only be used in the short term due to the risk of augmentation. Note the need to warn the patient about the risk of impulse control disorders. Please contact neurology for guidance.
Where the drugs don’t work or stop working consider
- Weaning off and re-starting after a wash-out period.
- A short course of a low dose of a hypnotic (e.g., clonazepam)
- If the patient is still struggling despite reasonable intervention then you could try referring them to the sleep team, who are respiratory physicians
Headaches
If the patient has a ‘Thunderclap Headache’ or you are worried about raised intracranial pressure then the patient needs to be assessed in ED or AMU. There is a lot of information about acute severe headache on the inpatient headache management pathway, including when to suspect ‘Thunderclap’ headaches.
If you or the patient are concerned that they may have a brain tumour you can get a direct access brain scan. Although a lot of people with brain tumours do have headache, less than 1 in 1000 people with headache have a brain tumour.
If the headache is ever bad enough to make the patient want to go and lie down somewhere, then it is well worth considering and treating for migraine.
Pain that is side-locked (always affects one side of the head) it is worth considering cluster headache or related conditions. One of the frequently seen features is ‘agitation’ when the headache is at it’s worst; pacing around, rocking backwards and forwards ect. If you genuinely believe that your patient has cluster headache or something similar then the patient should be referred to the neurology department.
If the pain is just in the distribution of the trigeminal nerve, is triggered by light touch and is at least partially relieved by carbamazepine then consider trigeminal neuralgia.
Tension type headache
Tension type headache is present for long periods of time. It can feel like a tight band around the head.
It can be triggered by musculoskeletal problems in the neck (you can feel the patient's neck and find that the muscles are very stiff), or dehydration.
Suggest neck exercises as outlined in the Chartered Society of Physiotherapy (CSP) videos.
Medication overuse headache
This commonly complicates migraine and tension type headache.
If the patient is taking any analgesic for more than 15 days a month, tell them to stop if they want the headache to go away.
Numbness and tingling
The two things that people worry about with this are multiple sclerosis (MS) or peripheral neuropathy.
Although both of these things can present as just tinging and numbness and you can actually have the pathological process that causes MS without having had any symptoms, usually numbness and tingling is nothing to worry about. The important thing really is whether the problem is persistent or temporary; symptoms that come and go are often benign.
There are a few nerves and nerve roots that are commonly compressed; if you suspect this you can get nerve conduction studies and then onto the peripheral nerve surgeons (Trauma and Orthopaedics, T&O).
| Numbness | Syndrome | Nerve |
|---|---|---|
| Lateral thigh | Meralgia paresthetica | Lateral cutaneous nerve of the thigh |
| Palm and forearm | Carpal Tunnel | Median |
| Pinkie and ring finger | Ulnar or C8 nerve root | |
| Foot | Tarsal Tunnel | Posterior tibial or L5 nerve root |
Post-concussion syndrome/mild traumatic Brain Injury
There is a concussion clinic run by the neurosurgery department at UHB.
The SCAT6 and SCOAT6 tools have been developed to help diagnose concussion.
If the patient has any of the Red Flags listed in the SCAT 6 tool they should be evaluated in ED and relevant imaging should be considered.
The symptoms or concussion or mTBI can continue for quite some time, although 70% of people will recover within 6 weeks.
It is better to treat post—traumatic headache as migraine with NSAIDS in the shorter term and medications like amitriptyline for persistent headaches rather than codeine etc.
It is worth addressing issues like insomnia, fatigue, brain fog, dizziness and anxiety.
Irritability is common because people with mTBI often struggle with concentration and multitasking – following some of the brain fog advice can help with this.
Headway give lots of good advice on managing concussion and mTBI.
There is a concussion clinic run by the neurosurgery department at UHB.
Patients who have had a severe TBI may benefit from assessment and treatment by the Brain Injury Specialist Clinic (which also provide assistance to patients who have had brain injury due to strokes or infections)
‘Return to play’ after concussion
Your patient should be assessed impaired memory, balance and co-ordination by a trained practitioner using the SCAT-6 or SCOAT-6 assessment tool. Once the patient has a normal score they can start ‘Light Exercise’
- Light exercise – walking, swimming, stationary bike with<70% of maximum heartrate. If there are no return of the above signs or symptoms the patient can progress to ‘Sport Specific Exercise’
- Sport specific exercise – aerobic training; running drills etc. but no contact training and no drills involving excessive cognitive input (i.e. so for footballers for example no heading, no passing, no tackling). If there is no recurrence of the above symptoms the patient can progress to ‘Non-contact training Drills’.
- Non-contact training drills – this can include all non-contact training and some strength training. If no recurrence of symptoms the patient can progress to ‘Full contact training’.
- Full contact training – it would be advised to repeat the SCAT-6 or SCOAT-6 prior to resuming this. If there is no recurrence of symptoms the patient can return to play.
Limb pain
Pain in one limb is seldom dealt with by neurology. The commonest causes would be nerve root irritation or compression (which is managed by spinal surgery or the musculoskeletal pathway) or single nerve lesions which are managed by the peripheral nerve surgeons (Trauma and Orthopedics).
Other causes include thoracic outlet syndrome which is investigated and managed by vascular surgery or chronic regional pain syndrome, which is managed by the Chronic Pain Team.
If you think that multiple sclerosis (MS) or peripheral neuropathy may be the cause, please refer to the relevant pages to get more information about the referral pathways.
Muscle cramps and twitches
The commonest cause for muscle twitching is benign fasciculation syndrome – in this case the twitching will be visible and palpable.
If the patient has very widespread fasciculations, especially in the tongue or anatomical snuff box (back of the thumb), then please refer the patient to the neurology department, urgently via the advice and guidance system.
Myopathy and myositis are rare; usually the patient will have a very raised CK. The commonest causes are vitamin D deficiency, hypothyroidism or statins, so please check and correct these before referring.
Dizziness
Vertigo is usually caused by vestibular problems, and so is dealt with by Ear, Nose and Throat (ENT). The Head Impulse, Nystagmus, Test of Skew (HINTS) examination should be used to exclude a cerebellar
stroke.
Light-headedness is usually caused by postural hypotension. Rarely there is a neurogenic cause for this, but usually, where persistent is it investigated and managed by Cardiology.
Ataxia is a neurological issue and should be discussed with neurology, although in the absence of any clear changes on brain imaging, it is likely to be functional.
Dysequilbrium, the feeling of being off balance in the absence of any abnormal signs , may be persistent, postural, perceptual dizziness (PPPD).
Persistent Postural-Perceptual Dizziness (PPPD)
PPPD (sometimes called '3PD') is a condition where people feel dizzy or off-balance most days for 3 months or more. It often starts after an illness like vertigo, a migraine, or a head injury. Your brain stays on 'high alert' and becomes too sensitive to movement, light, and patterns.
PPPD is common, real, and treatable.
What are the symptoms?
People with PPPD might feel:
- Wobbly or swaying like on a boat
- Light-headed, floaty, or fuzzy-headed
- Dizzy in shops, while scrolling, or on patterned floors
- Anxious about falling (even if they don’t)
- Like they’re spaced out or ‘not quite there’
How is PPPD diagnosed?
There is no scan or blood test that shows PPPD. Doctors listen to your story. To make the diagnosis, symptoms must:
- Last 3 months or more
- Happen on most days
- Get worse with movement, standing up, or seeing lots of things moving
How is PPPD treated?
Most people get better with the right help. It takes time, but recovery is possible.
Treatment includes:
- Vestibular physiotherapy – gentle exercises to retrain your balance system
- Start by looking at a ‘busy’ image (see below) or patterned surface for 30–60 seconds
- Slowly add movement: turn your head, stand up, or shift weight side to side
- Stop and rest if symptoms get worse, then try again later
- CBT (Cognitive Behavioural Therapy) – to reduce fear of movement or falling
- Medication – antidepressants that help your balance system even if you aren’t depressed
- SSRIs: Sertraline (25–100 mg), Escitalopram (5–10 mg), Fluoxetine (10–20 mg)
- SNRIs: Venlafaxine (37.5–75 mg), Duloxetine (30–60 mg)
- These take 8–12 weeks to help and are often used for 6–12 months
Tips for Coping
- Keep moving a little every day
- Breathe slowly when symptoms appear
- Don’t push too hard on good days or give up on bad ones
- Try mindfulness or guided relaxation
Other websites
Last reviewed: 30 June 2026