What is PPPD?

Persistent Postural Perceptual Dizziness, or PPPD, is a change in the brain’s ability to interpret where we are in space or where we are moving (Stanford). This change is precipitated by an alarming event. This event can be a vestibular issue such as BPPV, peripheral vestibulopathy (hypofunction/loss), or central vestibular issue such as vestibular migraine. Alternatively, this event can be an emotional event such as the death of a loved one. Either way, the brain changes functionally, with different connectivity and “on/off” parts of the brain when exposed to visual stimulation or self-motion (Li et al., 2020); Indovina et al., 2021) There are usually no structural changes on a standard CT or MRI of the head. Therefore, the diagnosis is usually made following the Bárány Society’s Diagnostic Criteria for PPPD.

How common is PPPD? “Among adults in a dedicated multidisciplinary dizziness clinic, 53.4% of 292 patients with chronic dizziness had PPPD either as their sole diagnosis (9.2%) or more commonly coexisting with other illnesses (44.2%)” Meanwhile, it was identified as the diagnosis in about 20% of patients with dizziness at a neuro clinic and 14% at a primary care facility.- Staab, 2023

What are the Diagnostic Criteria for PPPD?

  1. Dizziness, non-spinning vertigo, unsteadiness (vague: “off feeling” for example)
  2. Duration at least 3 months
  3. Timing: Persistent, prolonged (hours), present most days, wax/wane
  4. Provoking factors: complex visual motion or patterns, active/passive head movement without directional preponderance, most notable upright
  5. Onset: trigger event (either distinct or gradual worsened symptoms to persistent level) including peripheral vestibular conditions, migraine, concussion, or psychiatric (anxiety/stress ex: loss of spouse)
  6. Significant distress or life impairment such as impaired daily activities
  7. Not better accounted for by other neuro-otologic disease or disease cannot fully explain all symptoms/level of disability (Staab et al., 2017)
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A deeper look at considerations for the Diagnostic Criteria for PPPD:

  1. Other diagnoses must be ruled out, or if found, then ideally confirmed/treated as able before a clear diagnosis of PPPD. For example, if BPPV is found on exam, it should be treated. Then, if the patient still fits the diagnostic criteria after the treatment, a PPPD diagnosis is possible. PPPD can co-occur frequently with vestibular migraine, anxiety, and/or depression, but again, they should be identified with appropriate criteria and/or testing. Then if the patient still fits the PPPD diagnostic criteria, they can be diagnosed with concurrent PPPD (Ak et al., 2022).
  2. Symptom duration on most days of 3 months or longer is a key part of the criteria, but there are predictors for who may develop PPPD. Medical professionals should watch out for “early signs” of PPPD and refer properly to vestibular rehab and/or psych support professionals (Popikov et al., 2018). In addition, clinicians should be aware of predictors for the development of PPPD: “Anxiety following vestibular injury, dependent personality traits, autonomic arousal, and increased body vigilance following precipitating events, and visual dependence, but not the severity of initial or subsequent structural vestibular deficits or compensation status, were the most important predictors of chronic dizziness.” – Trinidade et al., 2023
    In fact, PPPD has been suggested to be on a spectrum that preexists in the general population, but “atypical visuo-vestibular processing predisposes some individuals to visually induced dizziness, which is then exacerbated should vestibular insult (or more generalized insult) occur” (Powell et al., 2020).

  3. Symptoms can present differently in different people. Some patients are more sensitive to self-motion (active such as while walking or passive such as when riding on a train), while others are more bothered by visual motion (such as watching car traffic speed past). Some are bothered equally by both! Interestingly, in one recent study, “The patients in the active motion-dominant subtype were significantly older than those in the visual-dominant subtype” (Yagi et al., 2021).
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Hot Updates to PPPD literature!

Top 5 Recent Updates to PPPD Literature

  1. Per a recent meta-analysis, cognitive behavioral therapy (CBT) can have additive positive effects in reducing dizziness (as measured by the Dizziness Handicap Inventory or DHI), whether the patient is receiving Vestibular Rehabilitation Therapy, Selective Serotonin Reuptake Inhibitor (SSRI), or VRT combined with SSRI. (Zhang et al., 2024) So let’s refer to our psych support clinicians early and often.
  2. Assess for and treat BPPV early! Waiting an average of 25 days between onset of symptoms and treatment of BPPV significantly increases the likelihood of developing PPPD compared to a shorter duration of ~13 days or less, particularly in those who are elderly (Casani et al., 2023).
  3. Using the Niigata PPPD Questionnaire (below in Go-To Resources section) can help identify patients with likely PPPD. Specifically, “Among three exacerbating factors, visual stimulation was the most distinctive for PPPD. A visual stimulation factor (adding up scores from Q2, 4, 8, and 10) score of 9 exhibited the best sensitivity (82%) and specificity (74%) for discriminating PPPD from control diseases.” (Yagi et al., 2019)

Top Triggers for PPPD (if able to identify organic cause)

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Image: Habs et al., 2020

4. Vestibular migraine (VM) differs from PPPD in that VM patients are most sensitive to optokinetic stimuli (riding in a car looking out at the visual motion), while PPPD patients have greater visual motion sensitivity when exposed to complex visual motion (e.g. shopping mall). In addition, a history of motion sickness as a child is more common in VM. (Chang et al., 2024).

5. The autonomic nervous system may play a bigger role than previously suspected in the PPPD presentation. In one early study, non-invasive vagus nerve stimulation has been shown to significantly improved quality of life, as measured by the EQ-5D-3L, and depression, as well as less severe vertigo attacks/exacerbations and a decrease in total postural sway path as measured by posturography (Eren et al., 2018). Looking forward to more studies on this!

Learn more about PPPD and the autonomic nervous system with this great video by Julie Hershberg, PT, DPT, NCS at re+active therapy and wellness!

Go-To Resources for PPPD


A. Modified Motion Sensitivity Test – mMST for assessing self-motion sensitivity by Heusel-Gillig et al., 2022

B. Niigata PPPD Questionnaire

C. Visual Vertigo Analogue Scale

D. Situational Vertigo Questionnaire

E. Motion Sickness Susceptibility Questionnaire – Short Form

F. Free Trial for DizzyDx (clinical decision support tool)


A. Optokinetic videos for habituation to visual motion

  1. Gabrielle Pierce, PT

  2. Emory Dizziness and Balance

  3. VRT Technologies – moving lines and patterns with targets and metronome, built by Ed Kostek, PT, DPT, OCS

B. Clinicians with PPPD + migraine treatment ideas and resources

  1. Courses and resources for clinicians and patients – Dr. Lisa Farrell, PT, PhD, @its.about.balance.with.dr.lisa, symmetryalliance.com
  2. Vestibular Group Fit – Dr. Madison Oak, PT, @thevertigodoctor, thevertigodoctor.com; Dr. Paige Day, PT, the-dizzy-doctor-rehab.square.site/
  3. Trained CBT and vestibular clinical psychologist – Dr. Emily Kostelnik, PhD, @dremilykostelnik, thevestibularpsychologist.com/
  4. Clinician mentorship – Kregg Ochitwa, Physio north49therapy.mykajabi.com/oneoneone_info-page; The Dizzy Coaches dalybalance.com/dizzy-coaches-about-us
  5. Vestibular migraine specialist physician (telehealth) – Dr. Shin Beh, vestibularmd.com/home; Migraine coaching – Dr. Omid Moshtaghi, MD @migraine.mentor