Management
Management & rehab
PPPD responds — often well — to treatment, and the first dose is a clear explanation. The three evidence-based pillars work alone and work better together.
It starts with the diagnosis
The single most helpful first step is a clear, confident explanation: the dizziness is real, it is not dangerous, the balance organs are working, and it can be improved. Understanding why it happens — and that avoidance makes it worse — sets up everything else.
Give the diagnosis positivelyand explain the mechanism — a retained, over-cautious balance “setting” after a real trigger. This reframing reduces fear and avoidance and is itself therapeutic; it also makes sense of why graded exposure, not rest, is the treatment.4
Avoid the trap of repeated negative investigations and vague labels, which entrench illness beliefs. A confident, mechanistic explanation — “software, not hardware” — is the foundation on which rehabilitation, medication and CBT build.4
The three pillars
Three treatments have evidence in PPPD, used singly or — best — combined, alongside treatment of any co-morbid migraine or anxiety.
Balance retraining (with gradual exposure to busy visual settings), a type of antidepressant that calms the dizziness, and a talking therapy that tackles the fear and avoidance — these are the mainstays, and they work well together.
Vestibular rehabilitation with visual desensitisation reduces symptoms and visual dependence;1 an SSRI/SNRI at therapeutic dose helps irrespective of overt depression;2 and CBT reduces the fear, avoidance and hypervigilance that perpetuate it.3
Start low and titrate SSRIs/SNRIs, warn about transient early worsening, and allow 8–12 weeks; benefit is often partial, which is why combination matters. Avoid long-term vestibular suppressants, which entrench avoidance. Treat coexisting vestibular migraine and anxiety/depression in parallel — unaddressed co-morbidity is a common reason for non-response.4
Explain & rehabilitate
- Positive diagnosisName it and explain the mechanism — a retained, over-cautious balance 'setting' after a real trigger. The explanation itself is therapeutic.
- Vestibular rehabilitationGraded habituation and balance retraining re-normalise automatic postural control; first-line and well tolerated.
- Visual desensitisationStructured exposure to busy/moving visual environments reduces visual dependence and visual vertigo.
Medication
- SSRI / SNRIA serotonergic antidepressant at therapeutic dose, irrespective of overt depression — start low, titrate, allow 8–12 weeks.
- Set expectationsBenefit builds over weeks and is often partial; warn about transient early side-effects to support adherence.
- Avoid suppressantsVestibular sedatives (e.g. long-term betahistine/benzodiazepines) do not help and can entrench avoidance.
Psychological & combined care
- CBTTargets the fear, avoidance and hypervigilance that perpetuate symptoms — even brief courses help.
- Treat co-morbiditiesAddress co-existing vestibular migraine and anxiety/depression; combined multimodal care gives the best outcomes.
Make the diagnosis positively, then combine the three pillars — vestibular rehabilitation, a serotonergic antidepressant, and CBT. Treat co-morbid migraine or anxiety alongside.
The course over time
A typical course runs from the explanation, through rehabilitation and medication, to combined and psychological care. Step through it:
Give the diagnosis positively and explain the mechanism — a 'software', not 'hardware', problem of postural control after a real trigger. Understanding it is therapeutic and underpins everything that follows.
The rehabilitation programme is covered in Vestibular rehabilitation therapy.
Key points
- A confident positive diagnosis and explanation is the essential first step — and is itself therapeutic.
- Three evidence-based pillars: vestibular rehabilitation (with visual desensitisation), SSRIs/SNRIs, and CBT.
- Combination works best; avoid long-term vestibular suppressants and repeated negative investigations.
- Treat coexisting vestibular migraine and anxiety/depression in parallel.