The Best Steps to Treating PPPD (Persistent Postural Perceptual Dizziness)

What is Persistent Postural Perceptual Dizziness (PPPD)?

In general, Persistent Postural Perceptual Dizziness (3PD or PPPD) is a condition resulting in long term dizziness that fluctuates in severity after an initial event or vestibular condition. Let’s break down the diagnostic criteria to better understand what 3PD and if this is something to seek out treatment for. 

PPPD Diagnostic Criteria

Here’s the check list your provider is looking at to determine if 3PD is the correct diagnosis and to then proceed with the most up to date treatment for this condition. 

All five criteria must be met for a PPPD diagnosis so let’s take a look: 

  1.  One or more symptoms of dizziness, unsteadiness, or non-spinning vertigo are present on most days for 3 months or more.

  • a. Symptoms last for prolonged (hours-long) periods of time, but may wax and wane in severity.

  • b. Symptoms need not be present continuously throughout the entire day


Translation: The dizziness does not have a spinning component and has lasted longer than 3 months. The dizziness or unsteadiness can vary in severity and get better or worse over hours or days, but is present a majority of the time. 

  1.  Persistent symptoms occur without specific provocation, but are exacerbated by three factors: 

  • a. Upright posture,

  • b. Active or passive motion without regard to direction or position, and

  • c. Exposure to moving visual stimuli or complex visual patterns.


Translation: Upright positions like sitting or standing feel worse than lying down. Both active motion (walking, bike, jogging) and passive motion (riding in a car or being pushed in a wheelchair) can both be aggravating no matter the position or direction you are in during the movement. And finally, busy environments or patterns can make symptoms worse (ex: busy crowds, walking by fences, changing sunlight from bright to shadows). 

  1. The disorder is precipitated by conditions that cause vertigo, unsteadiness, dizziness, or problems with balance including acute, episodic, or chronic vestibular syndromes, other neurologic or medical illnesses, or psychological distress.

  • a. When the precipitant is an acute or episodic condition, symptoms settle into the pattern of criterion 1 as the precipitant resolves, but they may occur intermittently at first, and then consolidate into a persistent course.

  • b. When the precipitant is a chronic syndrome, symptoms may develop slowly at first and worsen gradually.

Translation: There must be another condition or cause that occurs first that results in dizziness or unsteadiness. This includes vestibular condition (BPPV, migraine, neuritis etc) or a different medical condition (neurologic, psychological etc). The underlying condition can be acute or chronic and may change how your symptoms feel. If it is a new condition  that suddenly happened there may be some resolution of symptoms and gradually become more constant. If the underlying condition is chronic then there might be more of a constant presence of your symptoms that gradually get worse over time. 

  1. Symptoms cause significant distress or functional impairment.

Translation: Is my life being impacted by my symptoms? Are you limited in your ability to work, perform household tasks or hobbies? 

  1. Symptoms are not better accounted for by another disease or disorder. 1

Translation: Does any other condition better explain what you’re experiencing?


Can You Treat PPPD?

Yes yes yes!

Personally, we have found high PPPD treatment success when we stick to the four general steps to treating PPPD: 

  1. Find the underlying cause 
  2. Treat the anxiety 
  3. Initiate Vestibular Rehabilitation Therapy 
  4. Reduce safety behaviors (return back to daily life) 

1. Treat the underlying cause. It’s important to treat the underlying cause that started the dizziness and imbalance to begin addressing the core of 3PD. This is where treatment begins to get customized for the person because different underlying causes (BPPV, neuritis, migraine, panic attacks, neurologic conditions) require different interventions for best results. 

2. Treat the anxiety. If you’ve read this far, you might be wondering “What does anxiety have to do with this, this is the time this is being mentioned”. Research has shown an anxiety component with 3PD and those with more anxious or nervous personalities are more likely to develop 3PD. This research shows that addressing anxiety through therapy and/or medication is highly recommended for best results in the treatment and management in 3PD. If you aren’t a fan of medications, have a conversation with your doctor, sometimes meds can be useful in starting treatment and weaning off them once you’re further along in VRT. 2,3

3. Initiate Vestibular Rehabilitation Therapy (VRT). VRT is to help address the movements and situations that worsen your symptoms or you’re completely avoiding due to concerns of safety or making your symptoms worse. This is done with gradual progression of exercises based on your specific response and recovery. This helps get you to step number 4 as your sx reduce in frequency and intensity. 

4. Reduce safety behaviors (return back to daily life). Once symptoms are improving, the goal is to get you back to your typical movements and activities. This is done with exercises or practice of activities in a safe environment like in VRT. This may be practicing walking in open spaces or uneven ground without a cane or walking stick, or returning to activities like biking, driving your usual routes. 

Want to Learn More About Treating PPPD?

If you’re interested in learning more about the specific factors address in VRT to reduce PPPD symptoms, reach out to a vestibular therapist or consider joining our vestibular community that includes dozens of premium content modules of information and resources and a great community to support you! 


Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here. 




  1. Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, Bronstein A. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. J Vestib Res. 2017;27(4):191-208. doi: 10.3233/VES170622. PMID: 29036855; PMCID: PMC9249299. 
  2. Probs t T, Dinkel A, SchmidMühlbauer G, Radz iej K, L imburg K, Pieh C, Lahmann C. Psychological di s tres s longitudinal ly mediates the effect of vertigo symptoms on vertigo-related handicap. J Psychosom Res . 2017 Feb;93:62- 68. doi : 10.1016/ j . jpsychores .2016.11.013. Epub 2016 Nov 30. PMID: 28107895.
  3. Chiarel la, Giuseppe & Petrolo, C. & Riccel l i , Roberta & Giofrè, L . & Ol ivadese, G. & Gioacchini , F .M. & Scarpa, Alfonso & Cas sandro, E ttore & Pas samonti , Luca. (2016) . Chronic subjective di z z ines s : Analys i s of underlying per sonal ity factor s . Journal of Ves tibular Research. 26. 403- 408. 10.3233/VES-160590.

19 thoughts on “The Best Steps to Treating PPPD (Persistent Postural Perceptual Dizziness)”

  1. I have recently been diagnosed with PPPD after being “dizzy” for almost 4 years. It took many doctors and tests to get to this point, but feeling hopeful I can get somewhere positive.

    I think these steps are the way to go and I agree…
    – Find the underlying cause
    – Treat the anxiety
    – Initiate Vestibular Rehabilitation Therapy
    – Reduce safety behaviors (return back to daily life)

  2. AnnMarie Rivera

    Hi Dr. Madison!
    I check all the boxes for 3pd. I have joined VGF this week! 🙌🏻
    Are there classes or exercises(I’m sure there are) in the program specifically for 3pd and where can I find them?

  3. my boyfriend of 21 yrs.. has PPPD and he woke up on his birthday on September 21.. n felt really weird..He never took days off work . but he did that day for his birthday.. now it’s almost MAY and we have been to soooo many doctors. he’s seeing a neurologist now.. and we are trying to find out the cause of this.. he just an Xray of his neck. so we are waiting to find out .. It has been horrible to see him suffer.. I’m taking care him and the house but it’s OK cus I had Breast cancer 🎀 in 2015/16 and had 6 rounds of chemo.. so he took care of me.. and our 19 yr. old son Nicholas has been through me being sick and then COVID and his dad having PPPD so its been really rough on him too..so if anyone has any info please let me know.. thanks 😊 Suz

    1. Avatar photo

      Hello! I find that a neuro-otologist is the best doctor for this because they are neurologists of the inner ear. and then additionally a vestibular PT specialist. Most people don’t like treating dizziness, so doctors will send you to the next one. hope you find answers soon!

  4. Hi. I was diagnosed with chronic vestibular migraine 6 years ago as the result of an inner ear infection. First 3 months bedridden with spinning vertigo. It’s since settled into light, noise sensitivity, constant nausea, insomnia and problems with busy visual environments. I do the hyh diet, take magnesium , CoQ10, b and d vitamins. I’ve tried over 12 meds to no avail. I take odanesteron almost daily for nausea. I did VRT sessions for 6 months with a very good balance center and do VRT exercises daily.

    While chronic, my symptoms wax and wan. The location I live in is listed as a top migraine city due to weather, I can’t move. I do much better either mountains, at the shore, or during colder seasons. Heat, humidity and barometric changes are HUGE triggers.

    Due to the visual issue, I have self diagnosed PPPD as well, confirmed by my neurologist. Bending over repeatedly sets me off, ie gardening, and places like airports demand a wheelchair. I start bobbing and get nauseated. I can hike, swim, snorkel walk outside during good weather conditions no problem. I do get sick swimming without something visual to focus on, ie cloudy water.

    My question is what exercises assist specifically for pppd? I’m ok with screens, reading, tv etc even when feeling bad (in a dark room and assuming no wild shaky visuals on tv). I obviously get my balance through my vision mostly at this point. Navigating in the dark is bad.

    I do use theraspecs quite a bit depending on environment.

    1. Avatar photo

      Hi PPPD treatment ‘gold standard’ is a medication (usually SSRI/SNRI with your doctor) + cognitive therapy + VRT all at the same time. The weather can definitely affect VM and when the weather has big swings, that when you and your headache specialist need a plan of attack to keep your VM threshold high to help with the attacks.
      For PPPD VRT, that needs to be determined back at the balance center, there are not specific things that help anyone. I cannot tell you what to do exactly, as this is not medical advice and shall not be construed as such. Hope this helps 🙂

  5. Hi, thanks for this very helpful page. I was recently diagnosed with PPPD after having ruled out all other causes. I fit the classic symptoms. My symptoms seems to be getting worse as my gait and balance seem to be getting worse. I feel like I’m drunk and am frustrated bc in spite of the VRT, anxiety drugs, norepinephrine and therapy, I’m still getting worse. Do you see people who tend to get worse before getting better?

    1. Avatar photo

      Hi! sometimes but not always. PPPD is always always caused by something (it could be vestibular, otherwise medical, or a psychiatric disorder like anxiety/panic/etc.). I find the people who get worse often need an eval for VM with a certified headache specialist. If a headache specialsit is certain it’s not that then other causes should be looked into. Additioally, the PPPD needs to be addressed holistically, meaning from a mental health perspective, from having support from others, etc. Not just with VRT. The gold stanard is CBT + VRT + SSRI/SNRI

  6. Jill Radovanovic

    Hi Madison
    l have pppd and have been doing vrt and exposure therapy forv8 months. Some days l feel like it’s getting better then l take a dive.
    My head gets fuzzy and l feel spaced out.
    My neurologist has prescribed a snri but haven’t started yet.
    Can u recover without meds?
    l would like to join your program but lm based in Sydney Australia so not sure of your lives and time difference.

    1. Avatar photo

      Hi! The PPPD Gold standard of treatment is SSRI or SNRI, CBT, and VRT. The meds are never a requirement and i’ve seen people do well without them, but it does take a little more time typically, which is okay of course! ups and downs are normal, all things we cover in VGFit! The group program has others form AUS in it, everything is recorded and can be taken at any time of the day so live sessions are not an issue 🙂

  7. I had pppd for 9 years and its made my life hell i been to so many doctors hospitals had meds and sill got it exercise dont work I go ok for abit the more I move more it get it I get up in the morning I am all over places then I have to sit down I have it all day 7 day week I am back at the hospital next week to get more exercise I think their is know hope and I got this for life has any one Els got this like I have all time I just dont know what to do any more

    1. Avatar photo

      Congrats! Yes! I recommend the PPPD Course in Vestibular Group Fit (thevertigodoctor.com/register) and the Pregnancy & vestibular disorder module also in vestibular group fit to help you with both of these things!

Leave a Comment

Your email address will not be published. Required fields are marked *