The Complete Doctor Academy · AKT  Neurology NICE Guidelines, broken into bites
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Deck 3 · Neurology NICE guidelines · teach-then-check

NICE Neurology

Each guideline is broken into small boxes — one idea each. Read the box, then answer the quick check underneath. Tap Show answer to mark yourself.

NG217
Epilepsies
NICE NG217 (2022, updated 2025) — confirm at nice.org.uk
💡Core conceptThe big idea
  • Epilepsy is a tendency to recurrent, unprovoked seizures.
  • Diagnosis and drug choice are specialist-led; the GP recognises, refers and supports.
? Quick check
After a single unprovoked seizure, who should confirm the diagnosis?
Show answer
A specialist — refer urgently (seen within 2 weeks). Don’t label epilepsy or start drugs in primary care.
⚡The ruleFirst-line drugs
  • Generalised tonic-clonic: sodium valproate — but not in anyone able to become pregnant (use lamotrigine or levetiracetam).
  • Focal seizures: lamotrigine or levetiracetam first-line.
? Quick check
A 24-year-old woman needs treatment for generalised epilepsy. Is valproate appropriate?
Show answer
No — valproate is teratogenic and contraindicated in those who could become pregnant; use lamotrigine or levetiracetam.
⚡The ruleStatus epilepticus
  • A convulsive seizure lasting ≥5 minutes (or repeated without recovery) is a medical emergency.
  • First-line: benzodiazepine (IV lorazepam, or buccal midazolam/rectal diazepam in the community).
? Quick check
A seizure has lasted 6 minutes. What is the immediate treatment?
Show answer
Treat as status epilepticus — give a benzodiazepine (buccal midazolam in the community; IV lorazepam in hospital).
🎯Why it mattersSafety & driving
  • Advise about SUDEP, seizure triggers, and safety (baths, heights, swimming).
  • DVLA: must stop driving and notify; a car licence usually needs 12 months seizure-free.
? Quick check
How long seizure-free before a standard car licence may be reconsidered?
Show answer
Generally 12 months (Group 1); HGV/PSV rules are much stricter.
⚡The ruleValproate safeguards
  • Under an MHRA pregnancy-prevention programme; avoid in those who can become pregnant unless no alternative.
  • New rules restrict starting valproate in under-55s without two specialists’ sign-off.
? Quick check
Which agency mandates the valproate pregnancy-prevention programme?
Show answer
The MHRA — it also warns on topiramate and other antiepileptics in pregnancy.
🧠How to picture itRecognising seizure types
  • Focal aware: consciousness retained, e.g. an aura or one-limb jerking.
  • Absence: brief blank staring, eyelid flutter — 3 Hz spike-and-wave on EEG.
  • Juvenile myoclonic: early-morning jerks in a teenager.
? Quick check
A teenager has early-morning limb jerks and occasional generalised seizures. Likely syndrome?
Show answer
Juvenile myoclonic epilepsy — typically responds to valproate (or levetiracetam/lamotrigine in those who could become pregnant).
⚡The ruleAbsence & focal first-line
  • Absence: ethosuximide first-line (valproate second).
  • Focal: lamotrigine or levetiracetam first-line; carbamazepine an option.
? Quick check
First-line drug for childhood absence epilepsy?
Show answer
Ethosuximide.
🎯Why it mattersWomen & pregnancy
  • Prescribe folic acid 5 mg to those who might conceive.
  • Never stop antiepileptics abruptly in pregnancy — refer to a specialist.
? Quick check
What folic acid dose for a woman with epilepsy who could conceive?
Show answer
5 mg daily (high-dose).
CG150
Headaches in over 12s
NICE CG150 — headaches in over 12s; confirm at nice.org.uk
💡Core conceptThe big idea
  • Most headaches are primary (tension-type, migraine, cluster) — diagnosed clinically.
  • The job is to spot red flags and treat the common primaries well.
? Quick check
Name two headache red flags that need urgent action.
Show answer
Thunderclap onset (SAH), new headache with focal signs/raised-ICP features, or new temporal headache + jaw claudication (GCA).
⚡The ruleMigraine treatment
  • Acute: a triptan plus an NSAID or paracetamol (± antiemetic).
  • Prophylaxis: propranolol or topiramate (avoid topiramate in pregnancy); amitriptyline is an option.
? Quick check
First-line acute treatment for a moderate–severe migraine?
Show answer
A triptan combined with an NSAID or paracetamol; add an antiemetic if nausea is prominent.
⚡The ruleTension-type & cluster
  • Tension-type: simple analgesia (aspirin/paracetamol/NSAID); no opioids.
  • Cluster: high-flow oxygen + subcutaneous/nasal sumatriptan; verapamil for prevention.
? Quick check
How is an acute cluster-headache attack treated?
Show answer
High-flow oxygen plus subcutaneous or nasal sumatriptan — simple analgesia does not work.
🎯Why it mattersMedication-overuse headache
  • Frequent use of acute painkillers (especially opioids/triptans) can cause daily headache.
  • Management is withdrawal of the overused medication.
? Quick check
A patient takes codeine most days for daily headache. Likely diagnosis?
Show answer
Medication-overuse headache — treat by withdrawing the overused analgesic.
🧠How to picture itRed-flag headache screen (SNOOP)
  • Systemic (fever, weight loss); Neurological signs; Onset thunderclap.
  • Older (>50, new); Papilloedema / pattern change / positional.
? Quick check
A 50-year-old has a new thunderclap headache peaking in seconds. Action?
Show answer
Exclude subarachnoid haemorrhage — urgent CT (± lumbar puncture).
⚡The ruleMigraine prophylaxis detail
  • Propranolol (avoid in asthma) or topiramate (teratogenic — two contraceptives).
  • Riboflavin (B2) 400 mg is an evidence-based option; amitriptyline also used.
? Quick check
Which migraine preventive is avoided in asthma?
Show answer
Propranolol (a beta-blocker).
🎯Why it mattersMenstrual & pregnancy migraine
  • Menstrual: frovatriptan or zolmitriptan as mini-prophylaxis.
  • Pregnancy: paracetamol first; avoid triptans/NSAIDs where possible.
? Quick check
Preferred acute migraine drug in pregnancy?
Show answer
Paracetamol.
NG128
Stroke & TIA
NICE NG128 — stroke & TIA; confirm at nice.org.uk
💡Core conceptThe big idea
  • Stroke is a time-critical emergency — ‘time is brain’.
  • Use FAST to recognise; a persisting deficit means admit now, not clinic.
? Quick check
FAST-positive symptoms still present — clinic or emergency?
Show answer
Emergency admission for imaging and possible thrombolysis/thrombectomy.
⚡The ruleAcute ischaemic stroke
  • Exclude bleed with urgent CT, then aspirin 300 mg for 2 weeks.
  • Thrombolysis (alteplase/tenecteplase) within the licensed window; thrombectomy for large-vessel occlusion.
? Quick check
After CT excludes haemorrhage, what antiplatelet dose is given?
Show answer
Aspirin 300 mg daily for 2 weeks, then long-term clopidogrel.
⚡The ruleTIA
  • Give aspirin 300 mg immediately and refer to be seen within 24 hours.
  • ABCD2 is no longer used to delay specialist assessment.
? Quick check
Suspected TIA yesterday, now resolved. Action?
Show answer
Aspirin 300 mg now and specialist TIA assessment within 24 hours.
🎯Why it mattersSecondary prevention
  • Clopidogrel long-term (aspirin + dipyridamole if intolerant).
  • High-intensity statin; anticoagulate if AF (CHA₂DS₂-VASc).
? Quick check
Ischaemic stroke with AF — antiplatelet or anticoagulant long-term?
Show answer
Anticoagulant (a DOAC) for AF-related stroke, not an antiplatelet.
🧠How to picture itLocalise the stroke
  • ACA: legs > arms, incontinence, disinhibition.
  • MCA: face/arms > legs, aphasia.
  • Posterior/PICA: vertigo, ataxia, dysphagia, hoarseness.
? Quick check
Legs weaker than arms with new incontinence — which territory?
Show answer
Anterior cerebral artery (ACA).
⚡The ruleCarotid surgery
  • Symptomatic carotid stenosis >70% (NASCET) → carotid endarterectomy.
  • Refer promptly after a carotid-territory TIA/stroke with good recovery.
? Quick check
Stenosis threshold for endarterectomy after carotid TIA (NASCET)?
Show answer
Greater than 70%.
🎯Why it mattersAmaurosis fugax
  • Transient monocular ‘curtain’ visual loss = a TIA equivalent.
  • Source is carotid embolism via the ophthalmic artery — assess the carotids.
? Quick check
‘Curtain’ descending over one eye for minutes — diagnosis?
Show answer
Amaurosis fugax (carotid-territory TIA).
NG236
Stroke rehabilitation
NICE NG236 (2023) — stroke rehabilitation
💡Core conceptThe big idea
  • Recovery continues long after the acute event.
  • Rehab is multidisciplinary — PT, OT, SALT, psychology, nursing.
? Quick check
Which team delivers stroke rehabilitation?
Show answer
A coordinated multidisciplinary team (physiotherapy, occupational therapy, speech & language therapy, psychology).
⚡The ruleIntensity
  • Offer at least 3 hours/day of multidisciplinary therapy, on ≥5 days/week, as tolerated.
  • Screen swallowing early to prevent aspiration.
? Quick check
What therapy intensity does NG236 recommend?
Show answer
At least 3 hours a day of MDT rehab on 5 or more days a week, as the person can tolerate.
🎯Why it mattersDon’t miss
  • Screen for mood disorders and cognitive problems.
  • Address communication (aphasia) and spasticity.
? Quick check
Which two hidden problems should be actively screened after stroke?
Show answer
Depression/anxiety and cognitive impairment — both common and treatable.
⚡The ruleSwallow & nutrition
  • Screen swallowing before any oral intake; nil by mouth if unsafe.
  • Refer to SALT; consider NG feeding if unsafe swallow persists.
? Quick check
First step before giving food/drink after a stroke?
Show answer
A swallow screen (nil by mouth until safe).
🎯Why it mattersPost-stroke complications
  • Watch for shoulder subluxation, spasticity, pain, depression.
  • Offer early mobilisation and VTE prevention (intermittent pneumatic compression, not heparin routinely).
? Quick check
Preferred VTE prophylaxis in acute stroke?
Show answer
Intermittent pneumatic compression (not routine heparin).
NG71
Parkinson's disease
NICE NG71 — Parkinson’s disease; confirm at nice.org.uk
💡Core conceptThe big idea
  • A clinical diagnosis: bradykinesia + rigidity + resting tremor.
  • Refer untreated to a specialist; don’t start drugs first in primary care.
? Quick check
Name the motor triad of Parkinson’s disease.
Show answer
Bradykinesia, rigidity and a resting (‘pill-rolling’) tremor.
⚡The ruleDrug choice
  • If motor symptoms affect quality of life → levodopa first-line.
  • If less troublesome → dopamine agonist, levodopa or MAO-B inhibitor.
? Quick check
Motor symptoms are impairing daily life. Best first drug?
Show answer
Levodopa — most effective for function; agonists/MAO-B are alternatives when symptoms are milder.
⚡The ruleDrugs to avoid
  • Avoid dopamine-blockers: metoclopramide, prochlorperazine, typical antipsychotics.
  • For nausea use domperidone; for psychosis consider quetiapine/clozapine.
? Quick check
Parkinson’s patient needs an antiemetic — which to avoid and which to use?
Show answer
Avoid metoclopramide/prochlorperazine; use domperidone.
🎯Why it mattersNever stop suddenly
  • Abrupt withdrawal risks acute akinesia / neuroleptic-malignant-like syndrome.
  • Give medicines on time, every time in hospital.
? Quick check
Why must Parkinson’s medication never be stopped abruptly?
Show answer
Sudden withdrawal can cause acute akinesia or an NMS-like crisis; doses must be given on time.
🧠How to picture itParkinson-plus clues
  • Early falls + vertical gaze palsy → progressive supranuclear palsy.
  • Autonomic failure (postural drop, incontinence) → multiple system atrophy.
  • Poor levodopa response points away from idiopathic PD.
? Quick check
Parkinsonism with early autonomic failure suggests what?
Show answer
Multiple system atrophy (Shy–Drager).
⚡The ruleNon-motor symptom treatment
  • Drooling: glycopyrronium. Postural drop: midodrine. Daytime sleepiness: modafinil.
  • PD psychosis: quetiapine or clozapine (never typical antipsychotics).
? Quick check
Which antipsychotics are safe(r) in Parkinson’s psychosis?
Show answer
Quetiapine or clozapine.
🎯Why it mattersImpulse-control disorder
  • Dopamine agonists (ropinirole, pramipexole) can cause gambling, hypersexuality, shopping.
  • Ask about these at every review; reduce the agonist if present.
? Quick check
A patient on ropinirole develops new gambling. Cause?
Show answer
Dopamine-agonist impulse-control disorder — reduce/stop the agonist.
NG220
Multiple sclerosis
NICE NG220 (2022) — multiple sclerosis
💡Core conceptThe big idea
  • MS = CNS demyelination disseminated in time and space.
  • No single test is diagnostic; MRI and CSF support a clinical diagnosis.
? Quick check
Is a positive MRI alone enough to diagnose MS?
Show answer
No — diagnosis needs lesions disseminated in time and space; MRI/CSF support but don’t confirm alone.
⚡The ruleRelapse
  • A relapse = new/worsening symptoms lasting >24 hours without infection/fever.
  • Acute relapse: high-dose steroids (oral/IV methylprednisolone).
? Quick check
How long must symptoms last to count as an MS relapse?
Show answer
More than 24 hours, in the absence of infection or fever.
🎯Why it mattersSymptom care
  • Treat fatigue, spasticity, bladder symptoms and mood.
  • Watch for infection/fever unmasking old symptoms (Uhthoff’s / pseudo-relapse).
? Quick check
A febrile MS patient’s old symptoms flare — relapse or not?
Show answer
Likely a pseudo-relapse from fever/infection — not a true relapse; treat the infection.
🧠How to picture itHow MS presents
  • Optic neuritis: painful monocular visual loss, colour desaturation.
  • Uhthoff’s: symptoms worse with heat/exercise.
  • Lhermitte’s: electric-shock sensation on neck flexion.
? Quick check
Painful visual loss with reduced colour vision in a young adult?
Show answer
Optic neuritis — a common first MS presentation.
⚡The ruleSymptom control
  • Fatigue: amantadine. Spasticity: baclofen/gabapentin.
  • Nocturia: desmopressin. Urge incontinence: oxybutynin.
? Quick check
First drug for troublesome MS fatigue?
Show answer
Amantadine.
🎯Why it mattersDisease-modifying therapy
  • Specialist-initiated; natalizumab more effective than beta-interferon.
  • Stop a DMT if disease keeps progressing on it.
? Quick check
Who starts disease-modifying therapy in MS?
Show answer
A specialist (neurology) — not primary care.
NG59
Low back pain & sciatica
NICE NG59 — low back pain & sciatica; confirm at nice.org.uk
💡Core conceptThe big idea
  • Most low back pain is non-specific and improves with activity.
  • Screen for red flags (cauda equina, cancer, infection, fracture).
? Quick check
Which red flag needs same-day referral?
Show answer
Suspected cauda equina — new bladder/bowel dysfunction, saddle anaesthesia, bilateral leg symptoms.
⚡The ruleManagement
  • Encourage staying active and self-management; consider group exercise.
  • NSAID first-line for pain; don’t offer paracetamol alone, and avoid opioids for chronic pain.
? Quick check
First-line analgesic for non-specific low back pain?
Show answer
An NSAID (at the lowest effective dose); paracetamol alone is not recommended.
🎯Why it mattersDon’t over-image
  • Don’t routinely image non-specific low back pain in primary care.
  • Consider combined physical + psychological programmes for persistent, disabling pain.
? Quick check
Persistent disabling back pain despite NSAIDs — next step?
Show answer
A combined physical and psychological (rehabilitation) programme, not routine imaging or opioids.
🧠How to picture itSciatica vs simple back pain
  • Sciatica: leg pain below the knee, dermatomal, ± positive straight-leg raise.
  • Most sciatica improves; image only if it would change management.
? Quick check
Leg pain below the knee with positive straight-leg raise — term?
Show answer
Sciatica (lumbar radiculopathy).
⚡The ruleWhat NICE says NOT to do
  • Don’t offer paracetamol alone, opioids for chronic pain, or routine imaging.
  • Don’t use acupuncture; do use exercise and, if needed, a combined programme.
? Quick check
Is paracetamol alone recommended for low back pain?
Show answer
No — use an NSAID; paracetamol alone is not advised.
CG173
Neuropathic pain
NICE CG173 — neuropathic pain; confirm at nice.org.uk
💡Core conceptThe big idea
  • Nerve-injury pain is burning, shooting, tingling and responds poorly to ordinary analgesia.
  • It needs specific neuropathic agents, not escalating opioids.
? Quick check
Why won’t ordinary painkillers fix neuropathic pain?
Show answer
Because the mechanism is nerve dysfunction; it needs agents like amitriptyline, duloxetine, gabapentin or pregabalin.
⚡The ruleFirst-line choices
  • Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin.
  • If the first doesn’t work, switch to another of these.
? Quick check
First-line drug options for neuropathic pain (non-trigeminal)?
Show answer
Amitriptyline, duloxetine, gabapentin or pregabalin — switch if one fails.
🎯Why it mattersThe exception
  • Trigeminal neuralgia is treated first-line with carbamazepine.
  • Refer if control is poor or diagnosis is uncertain.
? Quick check
First-line drug for trigeminal neuralgia specifically?
Show answer
Carbamazepine — the standout exception to the usual neuropathic-pain list.
🧠How to picture itSpot neuropathic pain
  • Burning, shooting, electric, tingling; allodynia (pain to light touch).
  • Common causes: diabetes, post-herpetic, sciatica, chemotherapy.
? Quick check
A diabetic has burning, tingling feet with allodynia. Pain type?
Show answer
Neuropathic pain.
🎯Why it mattersPractical prescribing
  • Start low, titrate; review at each step; only switch if a full trial fails.
  • Capsaicin cream is an option for localised neuropathic pain.
? Quick check
A localised patch of neuropathic pain — topical option?
Show answer
Capsaicin cream.
NG127
Suspected neurological conditions: referral
NICE NG127 — suspected neurological conditions; confirm at nice.org.uk
💡Core conceptThe big idea
  • A symptom-based guide: what to do when someone presents with a neurological symptom.
  • It defines who to refer, how urgently, and what first tests to do.
? Quick check
What does NG127 organise its advice around?
Show answer
Presenting symptoms (e.g. headache, blackouts, tremor, dizziness) rather than established diagnoses.
⚡The ruleBlackouts
  • Record a 12-lead ECG in anyone with a transient loss of consciousness.
  • Get a witness account — it is the single most useful diagnostic tool.
? Quick check
First investigation after a blackout?
Show answer
A 12-lead ECG, to exclude a cardiac (arrhythmic) cause — plus a witness history.
🎯Why it mattersUrgent referrals
  • Progressive weakness, new cognitive/behaviour change, or suspected MS/MND → refer.
  • Match urgency to red flags, not to patient anxiety alone.
? Quick check
Give one presentation warranting urgent neurology referral.
Show answer
Progressive or persistent focal neurological deficit (e.g. suspected MND/MS or a space-occupying lesion).
⚡The ruleBell’s palsy
  • LMN facial palsy with forehead involvement; start prednisolone within 72 h.
  • Protect the eye (lubricants, tape at night).
? Quick check
First-line drug for Bell’s palsy within 72 hours?
Show answer
Prednisolone.
🎯Why it mattersWhen to image urgently
  • New focal deficit, suspected stroke, or first seizure with focal features → urgent.
  • Progressive headache with red flags → refer for imaging.
? Quick check
A first seizure with new focal weakness — urgency?
Show answer
Urgent specialist assessment and imaging.
NG206
ME / chronic fatigue syndrome
NICE NG206 (2021) — ME/CFS (GET no longer recommended)
💡Core conceptThe big idea
  • ME/CFS is a real, disabling condition; the hallmark is post-exertional malaise (PEM).
  • Diagnose if symptoms persist ≥3 months with PEM, unrefreshing sleep and cognitive difficulty.
? Quick check
What is the hallmark symptom of ME/CFS?
Show answer
Post-exertional malaise — a disproportionate worsening of symptoms after activity, often delayed.
⚡The ruleWhat changed
  • Graded exercise therapy (GET) is no longer recommended.
  • Manage with energy management (‘pacing’) and personalised support.
? Quick check
Should graded exercise therapy be offered for ME/CFS?
Show answer
No — the 2021 guideline removed GET; use energy management/pacing instead.
🎯Why it mattersSupport, don’t dismiss
  • Validate the illness; avoid ‘it’s all in the mind’ framing.
  • CBT may be supportive (to cope), not curative.
? Quick check
What is the role of CBT in ME/CFS under NG206?
Show answer
A supportive option to help cope — not a cure and not a substitute for believing the illness is real.
🧠How to picture itMaking the diagnosis
  • Persistent (≥3 months) fatigue with PEM, unrefreshing sleep and cognitive difficulty.
  • Exclude alternative causes with basic bloods first.
? Quick check
How long must symptoms persist to diagnose ME/CFS?
Show answer
At least 3 months.
🎯Why it mattersManaging well
  • Energy management (pacing), symptom-targeted care, and a personalised plan.
  • Avoid pushing through activity — post-exertional malaise worsens the illness.
? Quick check
Should patients ‘push through’ activity in ME/CFS?
Show answer
No — that triggers post-exertional malaise; use pacing.