Classification of Persistent Postural Perceptual Dizziness and Complex Cases

A recent study suggests that patients are more likely to develop persistent postural perceptual dizziness (PPPD) if they have a history of multiple episodic conditions such as benign paroxysmal positional vertigo (BPPV), vestibular migraine (VM), or Meniere’s disease (MD) compared to those with a history of a single episodic condition. PPPD is a relatively new classification of vestibular/balance disorder.

In 2017, the Bárány Society published diagnostic criteria that is characterized by recurrent feelings of non-spinning vertigo and unsteadiness that persists for three months or more (Staab et al., 2017). These symptoms can worsen with certain movements and in some complex visual environments. Gabacorta et al., (2022) observed that PPPD criteria was met in 3.9 percent of subjects with a history of a single episodic condition (either BPPV, VM, or MD), whereas 22.4 percent of subjects with a history of multiple episodic conditions (two or more of BPPV, VM and MD) met the diagnostic criteria for PPPD.

Most notably, those with VM either singly or as one of the conditions were most likely to meet PPPD criteria. Those with MD also were more likely to develop PPPD compared to BPPV. PPPD can occur following other single episodic events such as vestibular neuritis. However, the current study did not include such subjects.

The proposed reason that subjects with VM and/or MD may be more likely to develop PPPD compared to BBPV is hypothesized to be due to the predictability of triggering BPPV symptoms compared to the less predictable mature of VM and MD. In other studies, a strong connection between PPPD and visual dependency and anxiety have been observed. Compared to those with VM and MD, decreased levels of anxiety have been reported in subjects with BPPV.

Clinically, this study highlights the importance of pathology morphing over time and can help in the counseling and education of patients with complex cases.

References

Gambacorta V, D’Orazio A. Pugliese V, Di Giovanni A, Ricci G, Faralli M. (2022) Persistent postural perceptual dizziness in episodic vestibular disorders. Audiol Res 12(16):589–595.

Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, Bronstein A. (2017) Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. J Vest Res: Equilib Orien 27(4):191–208.