Persistent postural-perceptual dizziness: a phenotype-oriented approach to practical management

Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder defined by persistent dizziness, unsteadiness, or non-spinning vertigo exacerbated by upright posture, active or passive motion, and visually complex environments. In clinical practice, however, the diagnostic label alone is often insufficient to guide management, because patients differ substantially in the relative prominence of visual dependence, motion-postural burden, multisensory provocation, affective-hypervigilant mechanisms, and migraine overlap.

To propose a clinically oriented, dimension-informed framework for translating a positive diagnosis of PPPD into individualized formulation and practical multimodal management.

This article presents a practice-oriented narrative synthesis rather than a systematic review or formal guideline. The literature was selected to inform clinical formulation, symptom profiling, assessment, treatment prioritization, and the interface between PPPD and vestibular migraine. The proposed framework is intended as a pragmatic clinical heuristic, not as a biologic taxonomy or a validated treatment-stratification model.

We organize PPPD heterogeneity around five anchor clinical phenotypes: visually dominant/visually dependent, active motion-postural, mixed/multisensory, affective-hypervigilant, and migraine-overlap/vestibular migraine-PPPD interface. These patterns are best understood as dominant clinical dimensions within a continuous and overlapping clinical space rather than as mutually exclusive phenotypes. This dimensional formulation may guide the weighting and sequencing of vestibular rehabilitation, psychologically informed interventions, migraine-oriented management, and selected pharmacologic treatment. It may also support the rational selection of assessment tools for clinical formulation and longitudinal follow-up. Prospective studies are needed to determine whether these clinical dimensions predict prognosis, functional outcome, treatment needs, or differential treatment response.