FND Education Project

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.

Quick Reference

Presentation: Confirm all five Bárány Society PPPD criteria; there is no single bedside manoeuvre or scan that establishes the diagnosis.

More techniques: See the full list below.

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For the Person With FND

You may feel unsteady while standing, as though you are rocking or swaying, or more dizzy when travelling or looking at a busy shop display. These are examples of what persistent postural-perceptual dizziness (PPPD) can feel like, but similar experiences have other causes. PPPD is a specific diagnosis; this page does not apply its criteria to every kind of dizziness. [1]

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.

What the assessment should help you explain

Bring a few ordinary examples: which activity became difficult, what help made it possible and what happened afterwards. Completing a short task in a quiet clinic leaves questions about repeated activity in your usual surroundings. Ask the team to record those questions rather than assuming a reassuring test means little disability.

The questionnaire and everyday-function guide gives clinicians a way to keep symptoms, participation and support needs visible. You do not need to provoke dizziness to make those needs count. You can also ask for support with distress, work, relationships or loss of confidence without agreeing that these caused your symptoms.

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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.

Preparing together

With permission, help assemble a short timeline and previous test results. Describe what you actually noticed and which assistance you provided, distinguishing this from what the person tells you they felt. Ask whether they want help remembering the explanation or communicating access needs. Do not answer every question for them or turn everyday life into a series of tests.

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For Clinicians and the Care Team

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.

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

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.

Diagnosis, measurement and coordinated care

Separate the five-criteria formulation, selected investigation findings and daily-function record. Ask vestibular medicine/ENT, neurology, physiotherapy, OT and primary care to clarify who owns each unresolved question. Record agreed access needs and reassessment arrangements. A mental-health assessment can address distress or a coexisting condition without being used as proof of PPPD.

The measurement guide distinguishes NPQ symptom scores from daily participation, assistance and recovery after activity. Explain questionnaire limitations before using scores to guide decisions. [2][3]

Technique outline: the five PPPD criteria

The preserved seven-step outline is now in Criteria and Clinical History. Use all five criteria together, with an explicit differential and follow-up plan.

Media contributor brief

The original static-diagram brief is preserved in the criteria guide. Text alternatives and consent remain necessary; moving visual demonstrations are not needed.

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Diagnostic techniques at a glance

The preserved eight-entry inventory retains the original descriptions and citations. The three detailed guides expand their use and limitations; not every entry is an independent diagnostic test.

Criterion A: persistent dizziness pattern

Required duration and background pattern.

Criterion B: three exacerbating factors

Separate history for posture, movement and visual surroundings.

Criterion C: precipitating condition

Onset and transition, including uncertainty about the precipitant.

Criterion D: meaningful impact

Distress and functional impairment, with daily-life context.

Criterion E: no better explanation

Positive criteria considered alongside alternative and coexisting explanations.

Vestibular and positional examinations

Indicated investigation of other balance conditions.

Orthostatic and neurological assessment

Indicated assessment of cardiovascular/autonomic and neurological contributors.

Symptom questionnaires

Structured symptom description alongside participation and support needs.

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]

  • NPQ development and later French and Korean validation inform the questionnaire guide. They support cautious measurement use, not a score-based substitute for the criteria. [2][3][4]

Citation table

Citation Figure 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.
[3] — Meletaki V, Gobinet M, Léonard J, Elzière M, Lopez C. French adaptation and validation of the Niigata PPPD Questionnaire: measure of severity of Persistent Postural-Perceptual Dizziness and its association with psychiatric comorbidities and perceived handicap. Frontiers in Neurology. 2024;15:1388805. DOI. FND-CIT-0262.
[4] — Kim HJ, Park JH, Kim JS. Diagnostic utility of Niigata Persistent Postural-Perceptual Dizziness (PPPD) Questionnaire (NPQ) for PPPD in comparison to dizziness handicap inventory. Journal of Vestibular Research. 2026;36(3):154–163. Published online September 23, 2025. DOI. FND-CIT-0271.

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

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