A functional vestibular disorder in which chronic dizziness, unsteadiness, or sensitivity to movement persists for three or more months after the triggering vestibular event has resolved. Not a structural disease — the inner ear is intact — but the symptoms are real and often disabling.
Medical definition
PPPD (Barany Society criteria, 2017) is defined by three core features that are present on most days for three months or more: (1) non-spinning dizziness or unsteadiness, (2) worsened by upright posture, active or passive movement, or visually stimulating environments, and (3) triggered or made worse by the same situations on an ongoing basis. It commonly follows vestibular neuritis, BPPV, panic disorder, mild traumatic brain injury, or any event that caused acute vestibular dysfunction. The vestibular system itself recovers; the central nervous system’s threat-detection and balance-monitoring circuits do not fully reset, and a state of heightened vigilance about balance persists.
Why it matters for vertigo
PPPD is one of the most commonly missed diagnoses I encounter in second-opinion consultations. Patients describe it as brain fog, wobbliness, or a floating sensation rather than spinning. Because the MRI and audiogram are normal, they are often told the problem is anxiety or stress. Sometimes anxiety is a co-contributor — but labelling PPPD as purely psychological and stopping there leaves the patient without treatment. PPPD has a specific management pathway: vestibular rehabilitation therapy, and in some cases, serotonin-active medication classes or CBT-based approaches. These are very different from what you do for BPPV or Meniere’s.
Where I see this in clinic
PPPD shows up most often in patients who had an episode of vestibular neuritis six months ago, recovered from the acute phase, but have never felt fully steady since. Or patients who had BPPV treated successfully but still feel “off” in crowded shopping malls or while scrolling on their phone. The pattern is the clue: normal MRI, normal audiogram, no episodic spinning, but constant background unsteadiness that gets worse with visual motion. In online consultations, identifying this pattern from history alone is entirely possible, and it is often the most valuable thing I can offer a patient who has been told nothing is wrong.
Related terms
Nystagmus — typically absent in PPPD, which helps differentiate it from active vestibular lesions. VNG — usually normal in PPPD except for mild oculomotor changes. Otoconia — BPPV caused by displaced otoconia is one common trigger event for PPPD. Canalithiasis — the resolved BPPV mechanism that sometimes leaves PPPD behind.
Medical Disclaimer: This glossary entry is for educational purposes only and is not a substitute for in-person clinical assessment. For a diagnosis and management plan, consult Dr. Prateek Porwal directly. WhatsApp: 7393062200.