Disorders · Introduction
Persistent postural-perceptual dizziness
The commonest cause of chronic dizziness — and one of the most missed. It starts with a real vestibular event, but the dizziness outlasts it: a persistent, non-spinning unsteadiness that is worse standing, worse moving, and worse in busy visual places.
What it is
PPPD is long-lasting dizziness and unsteadiness that continues for months after something set it off — often a bout of vertigo, a migraine, a panic attack or a head injury. It is not spinning; it is a constant off-balance, swaying or “foggy” feeling that gets worse when standing, moving about, or in busy places like supermarkets. The balance organs themselves are working — the problem is in how the brain is using them.
Persistent postural-perceptual dizziness is a chronic functional vestibular disorder: persistent non-spinning dizziness or unsteadiness on most days for three months or more, exacerbated by upright posture, motion and complex visual stimuli, and triggered by a precipitating event.1 It unifies the older concepts of phobic postural vertigo and chronic subjective dizziness.
Two themes run through this chapter. First, PPPD is a positive diagnosis made on its criteria, not a diagnosis of exclusion — though active structural disease must still be excluded.2 Second, it is genuinely treatable: a confident explanation, vestibular rehabilitation, serotonergic medication and CBT each help, and combined care helps most.3
By the numbers
PPPD is the most frequent cause of chronic vestibular symptoms seen in neuro-otology clinics, yet it is widely under-recognised and mislabelled.2 It most often follows an identifiable trigger:
Precipitating events
Illustrative distribution of precipitating events — a peripheral vestibular trigger (neuritis, BPPV) and vestibular migraine are the commonest.
How this chapter is organised
- Triggers & mechanism — the precipitants and the maladaptive postural control that perpetuates symptoms.
- Clinical features — the persistent, posture/motion/visual-provoked pattern.
- Diagnosis & criteria — the Bárány criteria (A–E) and an interactive checker.
- Differential diagnosis — vestibular migraine, BPPV, bilateral loss and orthostatic dizziness.
- Management & rehab — explanation, vestibular rehabilitation, SSRIs/SNRIs and CBT.
Key points
- A chronic functional vestibular disorder — persistent non-spinning dizziness for ≥3 months.
- Worse with the three exacerbators: upright posture, self-motion, and busy/moving visual environments.
- Triggered by a real event (neuritis, BPPV, vestibular migraine, panic, trauma) that has since resolved.
- A positive diagnosis on the Bárány criteria; vestibular tests are typically normal.
- Treatable — explanation, vestibular rehabilitation, SSRIs/SNRIs and CBT, ideally combined.