What is PPPD?

Persistent postural perceptual dizziness (PPPD) is a sensation of constant vague dizziness. It’s common to feel dizzy or lightheaded once in a while and thankfully the sensation isn’t usually serious, and usually goes away on its own (i). But if you feel dizzy on most days, and the dizziness has lasted for three months or more, you may be experiencing a condition called persistent postural-perceptual dizziness (PPPD or 3PD for short).
 
PPPD has been recognised as a medical condition since 2017, but its symptoms have been described since the 19th century. PPPD means symptoms persist throughout the day, worsen when upright or moving, and may not be obvious to others.
 

PPPD symptoms 

If you have PPPD you’ll usually experience three main symptoms – dizziness, non-spinning vertigo and feeling unsteady on your feet, as if you’re rocking or swaying. Your symptoms will usually feel worse when you’re in an upright position or whenever you’re in a busy visual environment – for instance in places and situations where there’s lots going on such as in a supermarket or restaurant, or any crowded place (including in busy traffic).
 
Other possible symptoms and complications can include:
 

• Headache or migraine 

• Difficulties with concentration (brain fog)

• Short-term memory problems 

• Feeling detached, spaced out

• Stiff neck

• Sensitivity to motion and/or light

• Fear of falling

• Agoraphobia 

• Anxiety 

• Depression 

• Tiredness

• Sensitivity to smells

 
According to the ICVD you have to meet the following five criteria before you can be diagnosed with PPPD:
 

1. You will have experienced dizziness of varying severity and lasting for hours on at least half of the days in a three-month period.

2. Your symptoms become worse with standing, while in motion and when you see complex patterns or moving stimuli.

3. Your symptoms were triggered by another condition (see What causes PPPD?, below).

4. Your symptoms affect your ability to carry out your usual daily activities.

5. Your symptoms aren’t caused by any other condition.

 

How common is PPPD?

PPPD is the most common chronic vestibular disorder (disorders affecting the inner ear) in people aged 30 to 50 years old (iv). However, it can affect anyone of any age, including children and is more prevalent in women, who are four times more likely to be affected by PPPD than men. The influence of female hormones, particularly during perimenopause and menopause, may contribute to its development.   

Mental health conditions are also associated with higher risk of PPPD as one study has found 42 per cent of people with PPPD also have anxiety or post-traumatic stress disorder (PTSD) (ii). However, PPPD can cause anxiety in some people, so we don’t really know exactly how PPPD and mental health conditions are related.
 
We also don’t know how many people overall have PPPD, but according to the Ménière’s Society, a UK study found four per cent of all people registered with a GP experience persistent symptoms of dizziness, the majority of whom say they’re severely affected (iii).
 
Thankfully PPPD isn’t considered a lifelong condition, and the symptoms often disappear after a few years (or sooner). People who get medical treatment for their PPPD symptoms, however, are thought to recover faster than those who don’t get any treatment (iv).
 

What causes PPPD?

Also sometimes called visual vertigo, phobic postural vertigo, functional dizziness or space and motion discomfort, PPPD is often triggered by another condition that affects the human balance system.
 

• Your inner ears (vestibular system)

• Your eyes

• Position sensors in your body

All of these things send information to your brain, which constantly adjusts your eyes, muscles and joints to stop you feeling dizzy.
 
There are several medical conditions that can affect your vestibular system,including benign paroxysmal positional vertigo (BPPV), labyrinthitis, Ménière’s disease, vestibular neuritis and vestibular migraine (migraine with other symptoms such as dizziness, vertigo, imbalance, nausea and vomiting). In fact, scientists have proposed there may be an association between migraine and PPPD (v). Other research suggests have that as many as one in four people who experience vestibular system disorders may go on to develop PPPD symptoms (vi).
 
The main theory of how PPPD develops suggests that if you’re affected by one of these vestibular conditions, your brain relies less on your vestibular system for maintaining your balance and more on the signals coming from your visual system (eyes). This causes problems with your balance system – and the more you notice it, the more you think or worry about it, and the stronger the sensations become. Even after the initial vestibular condition has cleared up, your brain can take a while to readjust properly, which explains why you still feel dizzy and unsteady on your feet for some time after you’ve recovered.
 

PPPD and mental health

PPPD can also develop in people who haven’t had a problem with their balance system. Sometimes it’s triggered by mental health conditions such as depression, anxiety, panic attacks or post-traumatic stress disorder (PTSD). 
 
According to the Vestibular Disorders Association (VEDA) 60 per cent of people with PPPD have clinically significant anxiety, with 45 per cent having clinically significant depression (only 25 per cent have neither) (vii). However, experts aren’t sure why some people with some mental health conditions seem to be more predisposed to developing PPPD than others.
 
Other things that can lead to PPPD include:

• Head injuries

• Whiplash

• Stroke 

• Heart rhythm problems 

• Low blood pressure

• Reactions to certain medications (blood pressure tablets, epilepsy drugs, sleeping tablets, antidepressants and anxiety medication for instance)

• Ear surgery

 

Should you see your GP?

Feeling dizzy every now and then isn’t usually a problem or a symptom of a medical condition, and most people won’t need to see their GP about it.
 
However, if feelings of dizziness don’t go away, or keep coming back for no obvious reason, it’s a good idea to tell your GP about your experience. According to the NHS (i), you should also see your GP if:
 

• You’re worried about your dizziness

• You’re experiencing problems with hearing and speaking

• You have ringing sounds in your ears (tinnitus) 

• You have problems with your eyesight such as blurred vision 

• Your face, arms or legs feel weak or numb 

• You have other symptoms such as nausea, vomiting, headache, fainting or collapsing or heart-rate changes

 

What else can cause dizziness?

Dizziness can be a symptom of several conditions besides PPPD, including some of the conditions thought to trigger it in the first place. Something as simple as an ear infection can make you feel dizzy, for instance, with others including BPPV, high blood pressure, migraine, peripheral neuropathy, brain tumour and stroke. So if you see your GP about feeling dizzy, they may want to rule out these and some other conditions before making a diagnosis.
 

PPPD Treatment 

 

Medication

 
Prescription medicines commonly used to treat depression called selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are often effective at treating both dizziness and the mental health problems that can accompany PPPD.
 
According to VEDA, clinical trials suggest SSRIs and SNRIs reduce symptoms by at least half in 80 per cent of people with PPPD who take them for at least eight to 12 weeks (viii). However, you must keep taking the medicines for at least a year to help prevent your symptoms coming back.
 

Vestibular rehabilitation

 
Vestibular rehabilitation is an exercised-based treatment programme for dizziness, aiming to help the brain relearn balance. Typically you’ll be referred to a hospital specialist who can teach you exercises for you to do at home - these are designed to train and integrate your eye, head and body movements.
 
Your therapist may also suggest you start to put yourself in situations that make you feel dizzy or uncomfortable slowly, so your balance system starts to work more effectively gradually. For instance, if you feel dizzy and unsteady while doing your weekly grocery shop, you could start by going to the supermarket for just one or two items, then add more items as you feel less dizzy and more stable.
 
VEDA claims a small-scale study has found vestibular rehabilitation may reduce the severity of vestibular symptoms by up to 80 per cent, and that it may help reduce PPPD-related anxiety and depression (vii).  
 

Cognitive behavioural therapy (CBT)

 
CBT is a talking therapy often used for mental health problems such as depression and anxiety. It aims to help you manage your problems by changing the way you think and behave, so that you deal with them in a more positive way.
 
CBT is also often used to treat dizziness as well as anxiety associated with dizziness and is often used alongside vestibular rehabilitation in the treatment of PPPD.
 

PPPD treatment at home      

If you feel persistently dizzy or unsteady on your feet it’s unlikely you’ll feel confident enough to do much or any exercise. But as your balance starts to improve, it’s a good idea to try getting more active, as regular physical activity is good for your balance system. Indeed, according to experts from NHS Lanarkshire, it’s very important to move as naturally as possible to allow your balance system to normal (viii). They also recommend the following simple balance exercises, which you can try yourself at home:
 

• Focus on a point in front of you (on a wall, for instance) and move your head up and down or from side to side (as if you’re signalling ‘no’ or ‘yes’). Keep moving your head until your PPPD symptoms start, then stop. Repeat this exercise two or three times a day. Your aim is to build up until you can continue for 30 seconds without feeling dizzy.

• Stand up and hold the back of a chair or something similar for balance if you need to. Then try placing your feet closer together than you would normally, and stand like that for 30 seconds. Gradually you should need less support. When you don’t need any support at all, try standing with your feet close together while doing other things – when you’re brushing your teeth, for instance. 

 
Meanwhile experts from University Hospital Southampton claim maintaining a healthy lifestyle through diet and exercise not only improves your physical and mental health, gives you a better night’s sleep better and relieves stress, but it can also reduce anxiety and the symptoms of PPPD (ix).
 
They also recommend meditation and mindfulness to help reduce the anxiety that often accompanies PPPD. Mindfulness, for instance, may help you feel as if your dizziness is no longer in control of you, helping you to accept it rather than fight it (which can make your symptoms worse).
 
Mindfulness helps you become more in tune with your thoughts, feelings, sensations and surroundings, so that you become more aware of the here and now and less concerned with what happened yesterday or what will happen tomorrow.
 
Find out more about mindfulness and how you can make it part of your daily routine by reading our article Using mindfulness to manage stress.
 

Supplements for PPPD      

As well as eating a healthy balanced diet you may want to consider trying nutritional supplements, as some have been shown to help with dizziness and vertigo as well as with migraine, which often precedes or accompanies PPPD:
 

Ginkgo biloba

 
Many people take ginkgo to boost their blood circulation, but there’s also evidence it may help relieve the symptoms of vertigo. One study, for instance, found almost half of people taking ginkgo recovered from their vertigo symptoms after three months, compared with almost a fifth of those who just took a placebo (dummy pill) (x). Researchers elsewhere have found ginkgo may significantly reduce residual dizziness in people with BPPV after they’ve had successful treatment for their condition (xi). However, consult your GP before taking a ginkgo supplement if you’re taking any blood-thinning medication, such as aspirin or warfarin.
 

Ginger

Often taken as a remedy for travel sickness, ginger has also been found effective for reducing vertigo in one small-scale study involving powdered ginger root (xii). Another study suggests ginger is as effective as a common migraine medicine in people who have migraine without aura (xiii).
 

Vitamin B2

According to the Health Supplements Information Service, one of the signs of vitamin B2 (riboflavin) deficiency is dizziness, along with poor concentration and memory, mouth ulcers and an eczema-like skin rash (xiv). This suggests that if you’re deficient in B2, increasing your levels may improve any dizziness you may be experiencing – though there haven’t been any studies that have found taking B2 could help in people with dizziness who already have normal or near-normal levels. Vitamin B2 could also help with migraine symptoms, with one study finding sufferers who took a B2 supplement had migraines on two days a month on average, compared to four days a month on average before they started taking the supplement (xv).
 

Magnesium

 
Many natural health practitioners recommend magnesium supplements for migraine as being low in migraine may increase your risk of having migraines. Studies have indeed found that people who have vestibular migraines – migraines with dizziness – may have low magnesium levels (xvi). Magnesium has also been used to treat vertigo with migraine in people who have had a particular type of surgery for hearing (xvii).
 

Coenzyme Q10 (coQ10)

 
Some scientists have suggested coQ10 may be helpful for people with vertigo and Ménière-like syndrome because it improves the immune system (xviii). A couple of study reviews, meanwhile, claim coQ10 may be more effective at reducing the duration of a migraine than a placebo, as well as lowering the number of migraine attacks per month (xix).
 

Lysine

 
Also called L-lysine, this is an essential amino acid (in other words, your body cannot make it so you have to get it from foods or supplements). If you’re low in lysine, you may experience dizziness (among other symptoms) (xx). According to VEDA there’s anecdotal evidence lysine may help reduce vertigo (xxi).
 

Need more information?

 
For more details about other conditions that cause dizziness, read our guides to vertigo and Ménière’s disease. There’s also lots more information on a wide range of other health conditions, including advice on self-care, in our pharmacy health library.
 

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Disclaimer: The information presented by Nature's Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor's care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.

 

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