What is the appropriate diagnostic and treatment approach for a patient presenting with dizziness (R42 code)?

Diagnostic and Treatment Approach for Dizziness (R42)

For a patient with nonspecific dizziness (R42 code), the diagnostic approach must begin with categorizing the vestibular syndrome by timing and triggers—not by the patient's subjective description—followed by targeted bedside examination maneuvers, with imaging reserved only for specific red flags. 1

Initial Clinical Assessment: Timing and Triggers Framework

The most critical first step is classifying dizziness into one of four temporal patterns, as this determines the entire diagnostic pathway 1, 2:

Brief Episodic Vertigo (seconds to minutes, triggered by head movements)

• Most likely diagnosis: Benign Paroxysmal Positional Vertigo (BPPV) 3, 1
• Episodes last <1 minute, specifically triggered by positional changes 1
• Perform Dix-Hallpike maneuver immediately—this is more diagnostic than any imaging or laboratory test 1, 4
• Positive findings include: 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms that crescendo then resolve within 60 seconds 1

Acute Persistent Vertigo (days to weeks, constant symptoms)

• Highest stroke risk category—requires differentiation between vestibular neuritis and posterior circulation infarction 3, 5
• Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) if trained—100% sensitivity for stroke detection versus 46% for early MRI 1
• Critical pitfall: 75-80% of posterior circulation stroke patients have NO focal neurologic deficits on standard examination 5

Spontaneous Episodic Vertigo (recurrent episodes without triggers)

• Consider Ménière's disease (associated with hearing loss, tinnitus, aural fullness) or vestibular migraine (headache, photophobia, phonophobia) 1

Chronic Vestibular Syndrome (weeks to months)

• Review medications first—this is the leading reversible cause 1
• Screen for psychiatric symptoms (anxiety, panic disorder, depression) 1
• Assess for posttraumatic vertigo history 1

Essential Physical Examination Components

Do not rely on patient descriptions of "spinning" versus "lightheadedness"—these subjective terms have poor diagnostic value 1, 5:

• Dix-Hallpike maneuver for triggered episodic symptoms 1, 4
• HINTS examination for acute vestibular syndrome (only if properly trained) 1, 4
• Orthostatic blood pressure measurement 6
• Assessment for nystagmus patterns (downbeating nystagmus indicates central pathology) 5
• Full neurologic examination for focal deficits 5

When Imaging Is NOT Indicated

No imaging is needed for 3, 1:

• BPPV with typical positive Dix-Hallpike test and no additional concerning features
• Acute persistent vertigo with normal neurologic exam AND reassuring HINTS examination by trained examiner
• Straightforward peripheral vestibular disorders responding to appropriate treatment

Common pitfall: Routine imaging for isolated dizziness has diagnostic yield <1% and most findings are incidental 5, 4

Red Flags Requiring Immediate MRI Brain Without Contrast

Order MRI (not CT) when any of these are present 1, 5:

• Focal neurological deficits (diplopia, dysarthria, facial numbness, limb weakness, sensory changes)
• Inability to stand or walk independently
• New severe headache with dizziness—mandates immediate imaging and neurology consultation
• Sudden unilateral hearing loss with vertigo
• Unilateral or pulsatile tinnitus
• Downbeating or other central nystagmus patterns
• Abnormal HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome
• Atypical or negative Dix-Hallpike in suspected BPPV (central positional vertigo risk)
• Failure to respond to appropriate vestibular treatments

Critical: CT head has only 20-40% sensitivity for causative pathology in dizziness and misses most posterior circulation infarcts—MRI with diffusion-weighted imaging is required 5, 4

Laboratory Testing

Laboratory testing is NOT routinely indicated for dizziness 4:

• Diagnosis is made through targeted history and bedside examination maneuvers, not blood work 4
• Consider CBC, basic metabolic panel, glucose only if orthostatic hypotension with suspected dehydration/electrolyte disturbance 4
• The most valuable "tests" are performed at bedside (Dix-Hallpike, HINTS), not in the laboratory 4

Treatment Based on Diagnosis

BPPV (Most Common Diagnosis)

Canalith repositioning procedures (Epley maneuver) are first-line treatment with 80% success after 1-3 treatments and 90-98% after repeat maneuvers 1:

• No imaging or medication needed for typical cases 3, 1
• Reassess within one month to document resolution 1
• Counsel about recurrence risk and fall prevention 1

Vestibular Neuritis

• Steroids may be beneficial 7
• Vestibular rehabilitation therapy for persistent symptoms 1, 6

Ménière's Disease

• Salt restriction, diuretics, intratympanic treatments 1

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1

Persistent Dizziness After Initial Treatment

Vestibular rehabilitation therapy is the primary intervention, significantly improving gait stability compared to medication alone 1:

• Includes habituation exercises, gaze stabilization, balance retraining, fall prevention 1
• Particularly beneficial for elderly patients or those with heightened fall risk 1

Regarding vHIT (Video Head Impulse Test) - Code 92700

vHIT is NOT indicated for straightforward BPPV or typical peripheral vestibular disorders 1:

• Comprehensive vestibular testing delays treatment and is unnecessary when clinical diagnosis is clear 1
• Consider vestibular testing only if: clinical presentation is atypical, Dix-Hallpike findings are equivocal, or additional symptoms suggest concurrent CNS or otologic disorders 1
• Medical necessity for vHIT cannot be established with only nonspecific R42 code—requires specific diagnosis and clinical indication for advanced vestibular testing

Critical Pitfalls to Avoid

• Do not assume normal neurologic exam excludes stroke—most posterior circulation infarcts present without focal deficits 5
• Do not order CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 5
• Do not order routine imaging for isolated dizziness with typical peripheral features—extremely low yield 5
• Do not skip bedside testing—Dix-Hallpike and HINTS provide more diagnostic value than imaging in most cases 5
• Do not rely on HINTS examination if not properly trained—results are unreliable when performed by non-experts 1