March 10, 2026
Persistent postural-perceptual dizziness (PPPD) has only recently been recognized as a unique vestibular condition. The chronic condition causes nonspinning dizziness and unsteadiness triggered by active or passive movement, standing, and visually complex environments. It's often associated with migraine and mental health issues.
"Common misconceptions are that PPPD is purely psychological and that there's no cure — neither of which is true," says Colton T. Clayton, Au.D., Ph.D., an audiologist specializing in vestibular disorders at Mayo Clinic in Jacksonville, Florida. "As a result, many people will see five or six specialists before they land on a final diagnosis of PPPD and an effective treatment pathway."
Mayo Clinic takes a unique approach to diagnosing PPPD that involves a coordinated team and comprehensive testing. The vestibular team has developed a treatment protocol that significantly reduces symptoms in nearly all people with PPPD. The team is also performing research and studies to improve test sensitivity and treatment adherence.
Distinguishing PPPD from other vestibular disorders
Diagnostic understanding of PPPD has evolved over the past decade, focusing now on multisensory testing and advanced interpretation of that testing. An assessment for PPPD includes testing the ears and vestibular function. In addition, balance is assessed by testing the eyes and proprioception.
"A lot of our testing will come back as normal, suggesting there are no ear deficits. We also rule out other vestibular issues, such as Meniere's disease and benign paroxysmal positional vertigo," Dr. Clayton says. "When we test for PPPD, we measure the eyes' response to movement. Our goal is to provoke a response and identify the environmental conditions that trigger PPPD symptoms."
The challenge for primary care physicians is identifying the signs of PPPD so it can be addressed in the early stages. Diagnostic criteria for PPPD, established by the Bárány Society and published in the Journal of Vestibular Research, require patients to meet five criteria:
- One or more symptoms of dizziness, unsteadiness or nonspinning vertigo are present on most days for three months or more.
- Persistent symptoms are exacerbated by upright posture, active or passive motion, and exposure to moving or complex visual stimuli.
- Prior conditions occurred that caused vertigo, unsteadiness, dizziness or balance issues.
- Symptoms cause significant distress or functional impairment.
- There is no presence of disease or condition that may account for the symptoms.
Dr. Clayton recommends that physicians also look for risk factors strongly associated with PPPD, such as a history of anxiety and hypersensitivity. He suggests referring patients to an audiologist if their dizziness lasts longer than a month and their symptoms don't improve with traditional treatments, such as medication and physical therapy.
A 2024 review published in Cureus reports an estimated prevalence of PPPD in nearly 20% of patients with vestibular symptoms. The estimated incidence of PPPD following acute or episodic vestibular disorders is 25%.
"PPPD is often initiated by a previous insult to the vestibular system," Dr. Clayton says. While the initial vestibular event resolved, the brain does not always readjust back to normal. "The longer patients live in this maladaptive space, the longer it takes to reverse it."
Comprehensive approach to PPPD treatment
Mayo Clinic achieves good outcomes with its collaborative and personalized approach to treating PPPD. Many patients see steady improvement in symptoms over the first several months of treatment. Progress may be slower for some — particularly those with comorbid factors, such as chronic migraine, hypersensitivity and inner ear damage. However, the team approach to assessment and treatment allows for earlier identification and mitigation of these potentially limiting factors.
"You'll very rarely have good success with a blanket treatment," Dr. Clayton says. "It comes down to what is specifically triggering for each patient."
PPPD treatment typically lasts 6 to 9 months and involves:
- Vestibular therapy that focuses on the patient's dominant trigger but addresses all three common triggers.
- Cognitive behavioral therapy (CBT) to manage stress, fear and anxiety associated with PPPD.
- Medication, specifically SSRI and SNRI antidepressants, that, may reduce dizziness and help manage mental health issues that accompany PPPD.
Dr. Clayton says the most significant barrier to PPPD treatment success is patient compliance.
"If people stick to the regimen, they'll see progress," says Dr. Clayton. "But retraining vestibular function takes time. Doing too much too soon can cause physical and mental stress that can stall progress. Proper pacing is critical."
Mayo Clinic's vestibular team has found that collaboration between specialties is critical for managing PPPD. The care team typically includes:
- Audiologists.
- Cognitive behavioral therapists.
- Neurologists.
- Otolaryngologists.
- Physical therapists.
Partnering with primary healthcare professionals and referring physicians is crucial for ongoing and long-term medication management.
Using research to address challenges in PPPD clinical care
Researchers continue to study PPPD to identify areas of improvement for diagnosing and treating the condition.
PPPD-related research interests include:
- Virtual options for vestibular therapy: Dr. Clayton is working to develop virtual reality and computer-based vestibular therapy programs to improve patient compliance. These options would enable patients to complete therapy at home with virtual support from a therapist.
- PPPD biomarkers: PPPD is often viewed as a diagnosis of exclusion. Mayo Clinic researchers are working to identify biomarkers and use that information to improve the sensitivity of testing.
- Nerve therapy for PPPD: Researchers are exploring vagus nerve stimulation as a potential treatment for PPPD. Mayo Clinic plans to begin a trial focused on vagus nerve stimulation for PPPD by the end of 2026.
"We still have a lot to learn about PPPD," Dr. Clayton says. "But what we do know is that with timely and comprehensive treatment, patients with PPPD can find relief."
For more information
Staab JP, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society. Journal of Vestibular Research. 2017;27:191.
Madrigal J, et al. Persistent challenges: A comprehensive review of persistent postural-perceptual dizziness, controversies, and clinical complexities. Cureus. 2024;16:e60911.
Refer a patient to Mayo Clinic.