Making the diagnosis
Diagnosis & criteria
PPPD is diagnosed by recognising a pattern, not by a test that “lights up”. The tests are mostly there to confirm that nothing else is going on.
The Bárány Society criteria
Doctors diagnose PPPD when five things are all true: the dizziness has lasted most days for three months or more; it is made worse by standing, moving and busy visual places; it began after a real triggering event; it is genuinely affecting life; and nothing else explains it better.
The 2017 consensus requires all five criteria: (A) persistent dizziness/unsteadiness on most days for ≥3 months; (B) worsened by the three exacerbating factors; (C) a linked precipitating event; (D) significant distress or impairment; and (E) not better explained by another disease.1
It is a positive diagnosis — you can make it confidently from the history at the first visit — but criterion E still demands that active structural or vestibular disease is excluded, and PPPD may co-exist with one.2 The Niigata PPPD Questionnaire quantifies severity across the three exacerbators and helps track treatment.3
The role of investigations
The diagnosis is clinical. Investigations mostly serve to exclude an active alternative — and a normal result supports PPPD rather than refuting it.
- History & examinationThe positive diagnosis — the symptom pattern and the three exacerbating factors, with a normal neuro-otological examinationdecisive
- Vestibular testing (vHIT, caloric, VEMP)Typically normal or non-explanatory; used to exclude active structural disease (a normal result supports PPPD)supportive
- Niigata PPPD Questionnaire (NPQ)A validated severity measure across the three exacerbating factors — useful to track treatmentsupportive
- PosturographyMay show a characteristic high-frequency, visually-dependent sway pattern, but is not required for diagnosisweak
- MRI (when indicated)Normal; reserved for red flags or atypical features to exclude central pathologyweak
PPPD is a positive clinical diagnosis; investigations are used mainly to confirm the picture and exclude active structural disease. Normal vestibular testing supports the diagnosis rather than refuting it.
Vestibular testing has its own chapters — vHIT, VNG (caloric) and VEMP; reserve MRI for red flags or atypical features.
Apply the criteria
All five limbs (A–E) are required. Persistent, posture/motion/visual-provoked symptoms are the core; the linked trigger, the impact, and exclusion of active disease complete the diagnosis.
Bárány criteria checker
Switch on each criterion that is present. All five (A–E) — persistent symptoms, the three exacerbating factors, a precipitant, significant impact, and exclusion of other active disease — are required.
Key points
- Diagnosis (Bárány 2017) requires all five criteria A–E.
- It is a positive diagnosis made on the history — but criterion E still requires excluding active disease.
- Vestibular tests are typically normal; a normal result supports the diagnosis.
- The NPQ quantifies severity and tracks response to treatment.