REFERENCE · DIAGNOSIS

Persistent Postural-Perceptual Dizziness

Refers to:

persistent non-spinning dizziness or unsteadiness;
rocking, swaying or visually induced dizziness; and
symptoms worsened by upright posture, movement or complex visual environments that meet PPPD criteria.

Scope boundary: PPPD is persistent by diagnostic definition—present on most days for at least three months—although severity can fluctuate. This page does not cover every brief dizzy spell, faint, balance problem or sudden fall; those appearances need their own differential assessment.

Featured technique: Criteria-based clinical interview with appropriate vestibular and medical assessment.
Diagnostic method: Confirm all five Bárány Society PPPD criteria; there is no single bedside manoeuvre or scan that establishes the diagnosis.
Media needed: A static criteria diagram. Moving visual patterns are not preferred because they may worsen symptoms.

Diagnostic techniques at a glance

Recovery reading: Thirteen detailed PPPD recovery and care pages, selected after assessment; treatment response does not establish the diagnosis.

Diagnostic techniques at a glance

These brief entries describe signs, observations, criteria and investigations clinicians may consider. They are not a checklist of tests everyone needs. Evidence and limitations differ for each entry; a positive sign must fit the whole clinical picture, including possible coexisting disease.

The longer explanations already on this page remain below. Individual technique pages will be developed and reviewed separately.

Criterion A: persistent dizziness pattern

The history establishes dizziness, unsteadiness or non-spinning vertigo on most days for at least three months. Symptoms typically last hours and may fluctuate. This is a required part of Bárány consensus criteria, not a standalone test. [1]

Criterion B: three exacerbating factors

Symptoms are worsened by upright posture, active or passive movement, and moving or visually complex surroundings. The clinician establishes all three domains from history; deliberate symptom provocation is unnecessary. Other vestibular conditions can share individual features. [1]

Criterion C: precipitating condition

The clinician establishes onset following a condition producing dizziness, imbalance or distress, such as an acute or chronic vestibular disorder. The course may consolidate as the precipitant changes. This requirement does not mean a psychological trigger must be present. [1]

Criterion D: meaningful impact

Symptoms must cause significant distress or functional impairment. The assessment records effects on daily life rather than requiring a particular severity score. Disability establishes impact, not the cause by itself. [1]

Criterion E: no better explanation

The full pattern must not be better accounted for by another disorder. Other conditions may coexist with PPPD. This differential requirement sits alongside positive symptom criteria; normal tests alone do not establish the syndrome. [1]

Vestibular and positional examinations

Head-impulse, nystagmus, positional and other indicated vestibular assessments investigate coexisting or alternative causes. There is no pathognomonic examination or laboratory test for PPPD. An abnormal vestibular test does not automatically exclude it. [1]

Orthostatic and neurological assessment

Where indicated, standing blood pressure, heart rate and neurological examination help distinguish cardiovascular or neurological causes of dizziness. These are differential investigations, not positive PPPD tests. [1]

Symptom questionnaires

Scales can characterize exacerbating situations and severity. The Niigata PPPD Questionnaire has validation research, but a questionnaire score supplements rather than replaces the full consensus criteria and differential assessment. [1][2]

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Persistent postural-perceptual dizziness (PPPD) is a specific diagnosis. This page does not apply its criteria to every kind of dizziness. The symptoms may be described as dizziness, unsteadiness or non-spinning vertigo and are often worse when upright, moving or looking at busy visual scenes.

The diagnosis is based on five criteria: symptoms on most days for at least three months; worsening with upright posture, movement and complex or moving visual information; onset after an event or condition that caused dizziness or imbalance; meaningful distress or interference; and symptoms not better explained by another disorder. All five are required. [1]

Vestibular tests or imaging may be normal, abnormal because of a coexisting condition, or show the problem that originally triggered PPPD. The diagnosis is not simply “normal tests plus dizziness.”

PPPD fluctuates, but established PPPD is persistent

PPPD is an important exception to a simple “episodic or persistent” rule. By definition, established PPPD is present on most days for at least three months. Symptoms usually last for prolonged, often hours-long periods, but may wax and wane and do not have to be present continuously all day. Brief flares can occur. After an acute or episodic precipitating illness, symptoms may be intermittent at first and then consolidate into the persistent PPPD pattern. Isolated brief dizziness episodes alone do not meet the PPPD criteria. [1]

When a familiar flare rises, protect against falls, stop driving or another hazardous activity, use the support or vestibular strategy already prescribed, and allow symptoms to settle enough to continue the graded plan safely. A new severe dizziness pattern, fainting, new hearing loss or focal neurological symptoms requires reassessment rather than being assumed to be a PPPD flare.

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For Family, Friends, and Other Supporters

Do not deliberately expose the person to supermarkets, scrolling patterns or rapid movement to test whether symptoms appear. These environments may be part of a carefully paced treatment plan, but diagnostic history does not require forcing an episode. Help describe the time course, triggers and daily impact instead.

During a flare

A person with PPPD can have a persistent background problem and still experience shorter periods when symptoms become much more intense. Help with fall safety, the usual mobility aid and the planned exit or recovery strategy. Reduce visual or motion demand enough to regain safety, but do not turn a temporary flare into an unplanned test or force exposure.

Useful history distinguishes the usual daily background from the stronger flare: what intensified it, how long the increase lasted and whether the person returned to their established baseline.

New severe dizziness, fainting, new neurological symptoms, chest pain or another concerning change requires appropriate assessment even after PPPD has been diagnosed.

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Persistent baseline, intermittent exacerbations

Document both the Criterion A background and superimposed exacerbations: how many days symptoms are present, typical hours per day, variation in severity, upright/motion/visual triggers, momentary flares, precipitating condition and recovery toward baseline. When an acute or episodic precipitant is involved, clarify whether early intermittent symptoms consolidated into a persistent course. Brief attacks alone should prompt consideration of episodic vestibular disorders rather than being labelled PPPD.

For an established patient, provide a short flare plan that preserves fall safety and an achievable baseline dose of vestibular/community activity while avoiding both hazardous overexposure and unnecessary prolonged avoidance. Reassess when the temporal pattern no longer fits the established diagnosis or suggests a coexisting episodic vestibular, neurological or cardiovascular disorder.

Technique outline: the five PPPD criteria

Criterion A—persistence: Establish one or more symptoms of dizziness, unsteadiness or non-spinning vertigo on most days for three months or more. Symptoms may wax and wane and need not last all day.
Criterion B—exacerbating factors: Confirm that persistent symptoms are worsened by upright posture, active or passive motion, and exposure to moving or complex visual stimuli. All three characteristic factors must be represented, although their effects may differ.
Criterion C—precipitant: Identify the vestibular, medical, neurological or psychological event that caused acute, episodic or chronic dizziness, unsteadiness or balance disruption, and establish a plausible transition into the persistent pattern.
Criterion D—impact: Confirm clinically significant distress or functional impairment.
Criterion E—exclusion: Determine that the symptoms are not better accounted for by another disease or disorder. Perform vestibular, neurological, cardiovascular or other assessment according to the presentation.
Document comorbid conditions rather than assuming they exclude PPPD. A person may have PPPD alongside a vestibular disorder, migraine or another condition when the complete criteria are met.
Explain which criteria are present, which alternative diagnoses were considered and what will prompt reassessment.

Media contributor brief

Create a static, accessible five-part diagram:

Most days for 3+ months
Worse upright, moving and with complex visual input
Began after a precipitating condition or event
Causes distress or impairment
Not better explained by another disorder

Add a separate note that all five criteria are required and that testing is selected to evaluate other or coexisting conditions. Avoid scrolling stripes, virtual supermarket footage, rotating patterns or autoplay animation. If visual examples are ever added, provide a static alternative first and a clear motion warning.

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Research and Sources

Evidence notes

The Bárány Society consensus paper defines PPPD through criteria A–E and states that the diagnosis is made from the history with examination and testing used to assess alternative and coexisting conditions. [1]

Citation table

Citation	Full citation
[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. Journal of Vestibular Research. 2017;27(4):191–208. FND-CIT-0027. https://doi.org/10.3233/VES-170622

[2]

Yagi C, Morita Y, Kitazawa M, et al. A Validated Questionnaire to Assess the Severity of Persistent Postural-Perceptual Dizziness (PPPD): The Niigata PPPD Questionnaire (NPQ). Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 2019;40(7):e747-e752. DOI. PMID: 31219964. FND-CIT-0156.

Technique outline created: August 24, 2026 · Vestibular-neurology and physiotherapy review pending

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