Tingling - red flag symptoms

Red flag symptoms in patients with tingling, how a good history can help identify the cause, possible investigations and when to refer.

A tingling sensation is sujective and can be difficult to describe, so ask the patient open questions (Photo: SPL)
A tingling sensation is sujective and can be difficult to describe, so ask the patient open questions (Photo: SPL)

Red flags

  • Onset after trauma, surgery or systemic infection
  • Multiple areas involved or progressive symptoms
  • Additional behavioural or memory changes
  • Fever or other systemic upset
  • Disturbances of autonomous nervous system or objective muscular weakness
  • Patient is at high risk because of age, existing chronic conditions or lifestyle factors

Tingling sensations (paraesthesia) are common and are often temporary and harmless. Patients tend to present if there is a sudden onset of tingling over a large area, such as an entire limb or face. They typically worry that they may be having a stroke. If a small area is affected or if symptoms recur over days or weeks, patients usually do not present for some time.


The experience of paraesthesia is subjective and can be difficult to describe. Patients may use terms such as 'trickling', 'pins and needles', 'like an electrical current' or descriptions such as pressure, tightness, heaviness or numbness. If the patient reports pain, neuralgia would be readily considered.

Details about the onset, timeline and any variability of the symptoms are essential to help understand progression or regression, any patterns (or lack of) as well as the emotional and functional impact.

An occupational history and details of physical activities may reveal a musculoskeletal strain. A recent travel history is useful (long-haul flights or long car journeys, possible infection risks). The patient should also be asked about lifestyle factors that could indicate cancers, acute or chronic infections, metabolic diseases or alcoholism, for example.

Do not forget to check if the patient is taking medications, if these have been recently started or changed, and if they have attempted to self-treat the paraesthesia. 

  • Simple, temporary local mechanical pressure (especially in elbows, shoulders, lower legs, cervical spine)
  • Chronic nerve compression syndromes such as carpal tunnel syndrome
  • Progressing arthritis, fibromyalgia, vertebral collapse or disc herniation, cervical rib, carcinomatosis, complex regional pain syndrome
  • Electrolyte disturbance (hyperventilation, dehydration, hyper- or hypoglycaemia)
  • Side-effects of medication such as benzodiazepines, SSRI withdrawal
  • Chemotherapy
  • Metal poisoning
  • MS or motor neurone disease
  • Brain or spinal compression processes, including abscesses, trauma, tumours or metastases
  • Sensory epilepsy or psychiatric conditions, such as somatoform disorders
  • Polyneuropathy of diabetes
  • Hypothyroidism or other metabolic conditions 
  • Barotrauma
  • Frostbite
  • Autoimmune conditions
  • Malnutrition or vitamin deficiency
  • Infections, for example, herpes simplex, HIV, varicella zoster, Lyme disease, Guillain-Barré syndrome or Bell’s palsy 
  • Acute limb ischaemia, thrombosis, chronic peripheral vascular disease
  • TIA or migraines

Short-term paraesthesia is most often caused by temporary pressure or other mechanical impact on nerves, but chronic paraesthesia is more likely to indicate a problem with the functioning of the anatomical neurons because of inflammation or poor circulation. 

This may result directly from a problem of blood flow in the area (for example, constrictions or obstructions, impact of heat or cold, infection-induced or autoimmune conditions) or from metabolic disturbances, such as electrolytes or blood glucose. 


Observe how the patient appears and behaves in the consultation. For example, do they seem confused or depressed?

A patient with large, multiple or unrelated areas affected would be of particular concern. Unless the affected area is clearly defined, it may not be possible to perform a complete neurological examination (sensation, sensory awareness, power, reflexes).

You should assess the movement of limbs and cervical spine. Any objective weakness or other neurological deficits would be significant until proven harmless.

Examine the skin for temperature differences or rashes, and check pulses as required. Note Lhermitte’s sign, with a neuralgic spinal sensation at neck flexion suggesting MS. Tinel’s and Phalen’s tests can be done on the wrists to assess for carpal tunnel syndrome, albeit with fairly poor reliability.


Consider baseline bloods to check for signs of inflammation, calcium and ESR, deficiencies in anaemia, vitamin B12, thiamin or ferritin, or metabolic dysfunction (liver, renal, glucose, thyroid). Nerve conduction studies may be indicated and useful, depending on your local facilities. In potential at-risk groups, such as smokers, consider a chest X-ray, even in the absence of other symptoms and normal chest auscultation. Other investigations, including spinal MRI or CT head, may be indicated, but discuss with a radiologist or neurologist first, if possible.

When to refer

Patients need to be investigated to identify the underlying diagnosis and referred promptly if they:

  • Have persistent or progressive symptoms
  • Have sudden onset or unusual distribution of symptoms
  • Have inconsistencies in history and findings
  • Are at risk, for example, are elderly, have diabetes or are in generally poor health
Test your knowledge

Which one of the following presentations would be the least worrisome?

  • An 81 year-old arthritic man who complains of persistently numb and weak hands after a fall out of bed
  • A 70 year-old long term smoker with haemoptysis and paraesthesia in his shoulders
  • A 21 year-old student with some stress issues and wrist pains. He is currently learning to touch-type 
  • A 45-year old man with recent unexplained weight loss, excessive thirst and frequent tingling in both of his feet
  • A 55-year-old with numbness over her neck, face and lower back, some chronic nausea, double vision, some dysarthria and recent memory problems 

Even though there could always be room for debate, the student suggests a presentation due to mechanical overuse, which may well be fully reversible with rest and time, whereas the other cases could well show signs of potential serious conditions, such as spinal trauma, cancer, new diabetes with neuropathy or cerebro-neurological pathology, such as a brain tumour or motor neurone disease.

  • Dr Jacobi is a GP in York

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This is an updated version of an article that was first published in May 2014.

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