Vestibular disorders are rarely simple. Many people who live with dizziness or vertigo eventually discover that their symptoms are connected not to a single condition, but to several overlapping diagnoses. This complex reality was the focus of a session at the Vestibular Disorders Association’s Life Rebalanced Live virtual conference titled “When Conditions Overlap: PPPD, Vestibular Migraine, and Other Comorbidities.”
The session brought together neurologists, Dr. Shin Beh and Dr. Kristen Steenerson, for a discussion about diagnosis and treatment, followed by a patient panel with Kayla McCain and Judi Rosenthal, who shared personal experiences navigating multiple conditions. Together, the conversation highlighted both the medical complexity of vestibular disorders and the lived experience of managing them.
Why Vestibular Conditions Often Occur Together
One of the most important points raised during the discussion is that vestibular conditions frequently overlap. Patients diagnosed with persistent postural-perceptual dizziness (PPPD) often also experience vestibular migraine, and conditions like benign paroxysmal positional vertigo (BPPV) or Meniere’s disease can appear alongside them.
Diagnosing these conditions begins with understanding the patient’s history—specifically the pattern of symptoms and what triggers them.
Vestibular migraine typically occurs in episodes that come and go, often accompanied by migraine-related sensitivities such as light sensitivity, sound sensitivity, nausea, or motion intolerance. These episodes can last minutes, hours, or even days.
PPPD, by contrast, is characterized by persistent dizziness that is present most days and often develops after an initial event—such as a vestibular illness, panic attack, or migraine episode.
Although the diagnostic criteria attempt to separate these disorders, the reality is that many patients experience symptoms that fall somewhere in between. In fact, the neurological pathways involved in migraine and PPPD overlap significantly, which helps explain why both conditions can occur in the same person.
Genetics, Hormones, and the Brain
Researchers believe several biological factors may increase a person’s vulnerability to developing vestibular disorders.
Some patients show early indicators of migraine sensitivity, such as childhood motion sickness or heightened sensory responses. Hormones may also play a role, which may help explain why vestibular disorders are more common in women and often emerge during times of hormonal fluctuation such as perimenopause.
Neurologically, migraine and PPPD involve overlapping brain circuits related to sensory processing, neurotransmitters like serotonin and dopamine, and the brain’s fear and stress response systems. When these systems become dysregulated, dizziness and sensory sensitivity can become chronic.
Stress and the “Threshold” Model
Stress is another factor frequently discussed in vestibular disorders. Experts emphasized that stress does not cause these conditions, but it can act as a trigger or amplifier.
One helpful way to think about this is the concept of a threshold. Each person’s nervous system can tolerate a certain level of sensory input and stress. When other factors—such as poor sleep, hormonal changes, illness, or vestibular dysfunction—lower that threshold, stress can push the system beyond its limit and trigger symptoms.
Understanding this relationship can help patients focus on strategies that increase resilience and stabilize the nervous system.
Treating Overlapping Conditions
Because vestibular disorders often involve multiple factors, treatment typically requires a multifaceted approach.
Doctors often begin by identifying whether a patient has both episodic conditions (like migraine or BPPV) and chronic conditions (like PPPD). Managing the episodic triggers is often the first priority, since repeated attacks can keep the nervous system in a heightened state.
Treatment plans commonly include:
- vestibular rehabilitation therapy
- lifestyle adjustments such as sleep regulation and stress management
- medications when appropriate
- gradual exposure to movement and sensory triggers
Experts emphasized that there is rarely a “magic bullet.” Recovery usually involves addressing several aspects of health at the same time.
Lifestyle Strategies
Lifestyle habits can play a significant role in managing vestibular migraine and related conditions.
Maintaining a regular sleep schedule is particularly important, since irregular sleep patterns can trigger migraine attacks. Diet may also influence symptoms. While individual triggers vary, reducing caffeine, alcohol, and highly processed foods can help some patients.
Rather than following extremely restrictive diets, clinicians often recommend balanced approaches such as the Mediterranean diet, which supports overall brain health.
The Role of a Multidisciplinary Care Team
Because vestibular disorders affect multiple body systems, care often involves a multidisciplinary team.
Core members of that team may include neurologists, vestibular specialists, and vestibular physical therapists. Depending on the patient’s symptoms, other professionals—such as cardiologists, psychologists, nutritionists, or exercise specialists—may also play a role.
Some patients also experience overlapping conditions such as POTS, Ehlers-Danlos syndrome, or fibromyalgia, which can further complicate treatment and require collaboration between specialties.
Patient Experiences with Overlapping Diagnoses
The second half of the session featured patient panelists sharing their experiences with complex diagnoses.
Judi described decades of symptoms beginning in childhood and eventually involving multiple diagnoses, including autoimmune disease, gastrointestinal disorders, and vestibular conditions. For her, the vestibular symptoms were the most disruptive because they made the world feel unfamiliar and disorienting.
Kayla described the sudden onset of dizziness in her twenties, which was eventually diagnosed as vestibular migraine. Years later, after experiencing new persistent symptoms such as visual bouncing and dissociation, she learned that she also had PPPD.
Both stories reflected a common theme in the vestibular community: diagnosis often unfolds gradually, and symptoms can evolve over time.
Looking Toward the Future
Although vestibular medicine still has many unanswered questions, researchers are making progress.
New clinical trials are investigating treatments specifically for vestibular migraine, including medications targeting the CGRP pathway and emerging neuromodulation devices. Researchers are also exploring additional migraine-related pathways that may lead to future therapies.
Perhaps most encouraging is the growing recognition that vestibular disorders require individualized, whole-person care.
For patients living with overlapping conditions, understanding how these disorders interact can be an important step toward finding effective treatment—and toward realizing they are not alone in their experience.
