Persistent Postural-Perceptual Dizziness (PPPD) After BPPV Resolved with Vestibular Rehabilitation
When the Crystals Clear but the Dizziness Doesn’t: Diagnosing and Treating PPPD in a 44-Year-Old Woman
PATIENT PROFILE
|
Age |
44 years |
|
Gender |
Female |
|
Occupation |
School Teacher |
|
City |
Bangalore |
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Presenting Complaint |
Daily dizziness, unsteadiness, and visual sensitivity persisting for 4 months after a confirmed, successfully treated episode of BPPV |
|
Diagnosis |
Persistent Postural-Perceptual Dizziness (PPPD), a chronic functional vestibular disorder |
|
Duration of Issue |
4 months of continuous symptoms following resolution of the underlying BPPV |
|
Previous Treatments |
BPPV treated successfully with the Epley manoeuvre; repeat Epley manoeuvres and a trial of anti-vertigo medication afterward gave no further benefit |
|
Date of Initial Consultation |
January 2026 |
|
Outcome |
Significant, sustained improvement in dizziness and function with vestibular rehabilitation therapy and low-dose SSRI |
THE PROBLEM
Condition
The patient first presented with a classic episode of Benign Paroxysmal Positional Vertigo (BPPV): brief, spinning vertigo triggered by rolling over in bed, confirmed on Dix-Hallpike testing and resolved the same day with the Epley manoeuvre. A repeat Dix-Hallpike test was negative, confirming the displaced otolith crystals had been successfully repositioned. What followed, however, would later be diagnosed by a neurologist in Bangalore as Persistent Postural-Perceptual Dizziness (PPPD), a chronic functional vestibular disorder that remains widely under-recognised in routine practice.
Despite this clear resolution, she continued to feel dizzy every single day for the following four months. The character of the dizziness had changed: it was no longer the brief, spinning sensation of BPPV, but a constant, low-grade rocking or swaying feeling, worse when standing or walking, and markedly worse in visually busy environments such as supermarket aisles, patterned flooring, or scrolling on a phone screen. She had no true spinning episodes during this period.
Because the symptoms began after a genuine vestibular event, they were initially, and understandably, treated as recurrent or residual BPPV. Repeat Epley manoeuvres were performed without benefit, and a trial of anti-vertigo medication made no meaningful difference. She was referred for a Vertigo Treatment opinion when it became clear the dizziness was not behaving like ongoing BPPV.
Emotional and Psychological Impact
By the time of referral, the patient had become increasingly anxious about the dizziness returning or worsening, and had started avoiding crowded places, busy classrooms during transitions between periods, and driving on flyovers. She described constantly monitoring her own balance and bodily sensations, a hypervigilance that seemed to make the dizziness more noticeable rather than less. As a teacher who spent most of her day standing and moving in front of a class, the persistent unsteadiness was affecting both her confidence and her ability to work normally. Part of the initial consultation focused on validating that her symptoms were real and physiologically explainable, not imagined and not a sign that the BPPV treatment had failed.
CONSULTATION & TREATMENT PLAN
What Was Assessed
- Detailed symptom history distinguishing episodic, spinning vertigo from the chronic, non-spinning dizziness typical of PPPD
- Application of Bárány Society diagnostic criteria for PPPD: persistent dizziness or unsteadiness for 3 months or more, present most days, and worsened by upright posture, active or passive movement, and exposure to complex or moving visual stimuli
- Repeat Dix-Hallpike and positional testing to confirm no recurrence of BPPV
- Head impulse test, oculomotor examination, gait assessment, and Romberg testing
- Videonystagmography (VNG) to exclude ongoing peripheral vestibular pathology
- Pure tone audiometry to exclude Meniere’s disease, given the overlapping complaint of dizziness
- GAD-7 and PHQ-9 screening for anxiety and depression, given the well-documented overlap between PPPD and anxiety disorders
- Review of the original BPPV treatment records to confirm true, objective resolution
- MRI brain and internal auditory canals to exclude a central or structural cause where clinically indicated
Why This Approach Was Chosen
PPPD is frequently mistaken for recurrent or incompletely treated BPPV, precisely because it so often follows a genuine peripheral vestibular event. The distinguishing feature is not the trigger, but the pattern: a shift from brief, positional, spinning vertigo to a chronic, non-spinning dizziness driven by posture, movement, and visual stimulation, in a patient whose original vestibular test has normalised. Since repeat manoeuvres and anti-vertigo medication had already failed to help, and her formal vestibular and audiometric testing was normal, the diagnosis pointed to a functional disorder of central vestibular processing rather than ongoing inner ear disease. Treatment was therefore built around retraining the brain’s balance and visual processing systems through structured vestibular rehabilitation, alongside a low-dose SSRI to help modulate the central pathways involved in both anxiety and chronic dizziness perception.
“PPPD is one of the most under-recognised causes of dizziness that persists after a vestibular event has actually resolved. Patients are often told, incorrectly, that their BPPV has come back, when in fact the brain has settled into a maladaptive pattern of processing balance and visual information. Once that is explained clearly, and treated with vestibular rehabilitation and, where appropriate, a low-dose SSRI, most patients improve substantially.” — Dr. Guruprasad Hosurkar.
BASELINE CLINICAL ASSESSMENT
Repeat Dix-Hallpike testing was negative bilaterally, confirming no recurrence of BPPV. Videonystagmography showed no evidence of ongoing peripheral vestibular dysfunction, and pure tone audiometry was normal, excluding Meniere’s disease. Gait assessment showed a mildly cautious, stiffened pattern, and Romberg testing was negative, though the patient subjectively reported feeling unsteady throughout testing. Optokinetic testing demonstrated marked visual dependence, with symptoms provoked by moving visual stimuli. GAD-7 scoring indicated mild-to-moderate anxiety. MRI brain and internal auditory canals showed no structural abnormality.
TREATMENT DETAILS
Step-by-Step Overview
- Structured patient education explaining PPPD as a recognised, diagnosable functional vestibular disorder, and explicitly distinguishing it from recurrent BPPV
- Vestibular Rehabilitation Therapy (VRT): habituation exercises, gaze stabilisation training, and balance retraining tailored to her specific triggers
- Graded exposure to visually stimulating environments, starting with static patterned surfaces and progressing to supermarket aisles, crowded corridors, and screen use
- Low-dose SSRI (escitalopram) started to help modulate central vestibular and anxiety-related processing, with the rationale explained clearly as distinct from treating depression
- Gradual up-titration of the SSRI dose over several weeks, with side-effect monitoring
- Basic cognitive-behavioural strategies to reduce hypervigilance and symptom-monitoring behaviour
- Structured follow-up at 4, 8, and 12 weeks using the Dizziness Handicap Inventory (DHI) to track functional improvement
Treatment Facts
|
Duration |
Approximately 3–4 months of active treatment, with continued SSRI maintenance thereafter |
|
Setting |
Outpatient neurology and vestibular clinic, KIMS Hospital, Mahadevapura, Bangalore |
|
Procedure |
Vestibular Rehabilitation Therapy combined with pharmacotherapy for PPPD |
|
Medication |
Low-dose SSRI (escitalopram), gradually up-titrated |
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Allied Therapies |
Vestibular physiotherapy, graded visual exposure, cognitive-behavioural strategies |
|
Complications |
None |
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Inpatient Admission |
Not required; fully managed on an outpatient basis |
POST-TREATMENT RESULTS
The Dizziness Handicap Inventory score improved from a severe baseline to a mild category by 12 weeks of combined treatment. Visual dependence on optokinetic retesting reduced substantially, and the patient reported a marked drop in day-to-day unsteadiness. She resumed driving, returned to shopping in busy supermarkets without triggering symptoms, and reported no further avoidance behaviour at work. The SSRI was continued at its effective low dose, with a plan to consider a gradual taper after 6 to 12 months of sustained stability an outcome that reflects the structured, multi-modal approach to vestibular rehabilitation championed by Dr. Guruprasad Hosurkar, a neurologist in Bangalore with extensive experience managing complex dizziness and functional vestibular disorders.
Outcomes at a Glance
|
Dizziness Handicap Inventory |
✔ Improved from severe to mild by 12 weeks |
|
Visual Dependence |
✔ Substantially reduced on repeat testing |
|
Return to Driving |
✔ Resumed without symptom recurrence |
|
Avoidance Behaviour |
✔ Resolved; returned to crowded and visually busy settings |
|
Anxiety Symptoms |
✔ Improved alongside dizziness with SSRI and VRT |
|
Complications |
✔ None |
PATIENT FEEDBACK
“After my vertigo attack was treated, everyone told me the crystals were fixed, but I still felt off every single day for months. I genuinely thought something had been missed. Dr. Guruprasad Hosurkar was the first person to explain that this was a separate, recognised condition and not a failed treatment. The physiotherapy exercises and the medication together made a real difference. I am back to driving and shopping normally, something I did not think would happen.”
- Profile: Female · 44 years · School Teacher · Bangalore
- Condition: Persistent Postural-Perceptual Dizziness (PPPD) following resolved BPPV, symptomatic for 4 months
- Neurologist:Dr. Guruprasad Hosurkar | KIMS Hospital, Mahadevapura, Bangalore | January 2026
POST TREATMENT CARE & RECOVERY
Instructions Given to Patient
- Continue daily home vestibular rehabilitation exercises even after symptoms improve, to consolidate central adaptation
- Continue the SSRI at the prescribed dose; any tapering to be done gradually and only under medical supervision
- Watch for relapse triggers such as acute stress, illness, or a further vestibular event, and seek review early if symptoms return
- Continue graded exposure to previously avoided situations rather than reverting to avoidance
- Repeat Dizziness Handicap Inventory assessment if symptoms fluctuate, to objectively track progress
- Routine follow-up review at 6 months to reassess the need for continued SSRI therapy
Recovery Timeline
|
Milestone |
Details |
|
Visit 1 (Month 0) |
PPPD diagnosed; vestibular rehabilitation and low-dose SSRI started; condition explained and distinguished from recurrent BPPV |
|
Week 4 |
Early reduction in constant background dizziness; SSRI dose gradually increased |
|
Week 8 |
Visual sensitivity improving; graded exposure to busy environments progressing well |
|
Week 12 |
DHI score improved from severe to mild; return to driving and unrestricted shopping |
|
Month 4–6 |
Sustained improvement; SSRI continued at stable dose; home VRT maintained |
|
Month 6–12 |
Planned reassessment for gradual SSRI taper if stability is maintained |
FAQs
1. What is Persistent Postural-Perceptual Dizziness (PPPD)?
PPPD is a chronic functional vestibular disorder causing daily dizziness, unsteadiness, or a rocking sensation that is worsened by standing, movement, and exposure to busy or moving visual environments. It commonly develops after a vestibular illness, even once that illness has been successfully treated.
2. How is PPPD different from BPPV or Meniere's disease?
BPPV causes brief, spinning vertigo triggered by specific head positions, and Meniere’s disease causes episodic vertigo with hearing loss and tinnitus. PPPD, by contrast, causes constant, non-spinning dizziness that persists on most days for three months or more, after the original triggering condition has resolved on testing.
3. Why did my dizziness continue after my BPPV was successfully treated?
In some people, the brain does not fully readjust after a vestibular event and settles into an altered, oversensitive pattern of processing balance and visual information. This is PPPD, a recognised functional disorder, not a sign that the original BPPV treatment failed or that crystals have returned.
4. How is PPPD treated?
The main treatments are vestibular rehabilitation therapy, which retrains balance and visual processing through targeted exercises, and low-dose SSRIs, which help modulate the central pathways involved in chronic dizziness and commonly-associated anxiety. Most patients see significant improvement with this combined approach.
5. Is PPPD a permanent condition?
No. With appropriate vestibular rehabilitation and, where needed, medication, most patients see substantial improvement over weeks to months. Some may taper off medication over time once symptoms are stable, while continuing home-based balance exercises.
Disclaimer: This case study is for educational purposes only. Patient identity has been withheld per confidentiality guidelines. For a related recovery story, see our Parkinson’s Disease case study, or browse more patient stories on our Case Study and Blog pages.