A New Approach to More Personalized Treatment
Persistent postural-perceptual dizziness (PPPD) is a chronic vestibular disorder that can cause ongoing dizziness, unsteadiness, or a sensation of movement even when a person is not actually moving. Symptoms are typically made worse by standing or walking, movement, and visually busy environments.
But anyone who has spent time with people who have PPPD knows that the condition does not look exactly the same in everyone.
A 2026 review published in Frontiers in Neurology proposes that recognizing these differences could help healthcare providers develop more individualized treatment plans. Rather than treating everyone with PPPD the same way, the authors suggest looking at which symptoms and triggers are most important for each person.
PPPD Is a Real and Recognizable Disorder
One important point the authors emphasize is that PPPD is not simply a diagnosis given when doctors cannot find another explanation for dizziness. It is a recognized functional vestibular disorder with specific diagnostic criteria.
To receive a PPPD diagnosis, a person must experience dizziness, unsteadiness, or non-spinning vertigo on most days for at least three months. Symptoms are worsened by upright posture, active or passive movement, and exposure to moving or complex visual environments. PPPD also develops following another event or condition that causes dizziness, unsteadiness, vertigo, or significant psychological distress.
Symptoms must cause significant distress or interfere with daily activities and cannot be better explained by another condition. An accurate diagnosis is essential before considering which PPPD symptom patterns may be most relevant to treatment.
PPPD often begins after another vestibular condition, such as vestibular neuritis, BPPV, or vestibular migraine. It can also coexist with other conditions. Anxiety may accompany PPPD without making the condition “psychological” or “all in your head.” Identifying and treating overlapping conditions is an important part of care.
Five Common PPPD Patterns
The authors propose five broad patterns, or “phenotypes,” of PPPD. These are not separate diagnoses, and people may fit into more than one category. Instead, they provide a way of identifying which problems are having the greatest impact on a particular patient.
Visually dominant PPPD
For these patients, visually busy environments are especially difficult. Grocery stores, shopping malls, traffic, escalators, patterned floors, scrolling on screens, or other moving visual scenes may trigger dizziness and sensory overload. Treatment may place greater emphasis on gradually helping the brain become more comfortable processing visual motion.
Motion and posture dominant PPPD
These patients are more affected by their own movement. Walking, turning, moving the head or body, or simply remaining upright may be especially challenging. Vestibular rehabilitation may focus more heavily on improving tolerance for movement, walking, turning, and maintaining balance.
Mixed or multisensory PPPD
Some people do not have one obvious dominant trigger. Visual stimulation, movement, and upright posture may all cause significant symptoms. These patients may benefit from a broader treatment plan that addresses several systems gradually rather than focusing primarily on one.
Anxiety and hypervigilance dominant PPPD
Some people become extremely alert to sensations of dizziness or imbalance and begin anticipating situations that might trigger symptoms. This can lead to avoidance and fear, creating a cycle in which dizziness and fear of dizziness reinforce each other. This does not mean anxiety causes or explains away PPPD. Instead, these responses can become one of several factors that help keep symptoms going. Psychological approaches such as cognitive behavioral therapy (CBT), combined with vestibular rehabilitation, may be particularly useful for these patients.
Vestibular migraine and PPPD overlap
Vestibular migraine is a common trigger or coexisting condition. Some patients have migraine-related episodes along with the more persistent background dizziness characteristic of PPPD. For these patients, it may be necessary to identify which symptoms belong to each condition and treat the migraine concurrently with PPPD rehabilitation.
Matching Treatment to the Patient
This approach does not mean that each type of PPPD has one specific treatment. Instead, the goal is to adjust the emphasis of treatment based on what is affecting the individual most.
Vestibular rehabilitation therapy (VRT) is an important treatment option. However, exercises should be customized. Someone whose symptoms are mainly visual may need carefully graded exposure to visual motion, while someone primarily affected by walking and movement may need greater emphasis on gait, turning, and movement tolerance.
Treatment should also address avoidance behaviors and incorporate a gradual return to symptom-provoking activities based on patient tolerance and progress. The goal is not to push through severe symptoms, but to gradually build tolerance and confidence through manageable challenges.
Patient education and realistic expectations are also essential components of treatment. Understanding why symptoms occur, how rehabilitation works, and why progress may be gradual can help patients participate more confidently in their recovery. Symptoms may fluctuate, and temporary setbacks do not necessarily mean treatment is failing.
Psychological support, particularly CBT and psychologically informed rehabilitation, may help address fear, avoidance, and hypervigilance. Medications such as SSRIs and SNRIs are also sometimes used, although high-quality evidence supporting medication specifically for PPPD remains limited.
What This Means for Patients
Perhaps the most encouraging message from this paper is that receiving a PPPD diagnosis should be the beginning of developing a treatment plan—not the end of the diagnostic conversation.
Two people can both meet the criteria for PPPD while having very different experiences. Understanding whether visual motion, physical movement, multisensory overload, hypervigilance, migraine, or a combination of these factors is driving disability may help clinicians prioritize treatment more effectively.
The authors caution that these five patterns have not yet been scientifically validated as official PPPD subtypes. More research is needed to determine whether matching treatments to these patterns actually produces better outcomes.
Still, the framework points toward an important goal in vestibular care: treating the person, not just the diagnosis. For people with PPPD, a more personalized approach may help clinicians identify what is keeping symptoms going, target rehabilitation accordingly, and adjust the treatment plan as symptoms and needs change over time.
Reference
Rey-Berenguel M, Vallecillo-Zorrilla J, Jimenez-Campos A, Espinosa-Sanchez JM. (2026). Persistent postural-perceptual dizziness: a phenotype-oriented approach to practical management. Frontiers in Neurology. https://doi.org/10.3389/fneur.2026.1879813
