The Functional Medicine Approach to Persistent Postural-Perceptual Dizziness (PPPD)

Persistent Postural-Perceptual Dizziness (PPPD) is a form of chronic dizziness that can severely impact people’s quality of life. This chronic functional vestibular disorder causes a persistent sensation of rocking or floating. It is the most common chronic vestibular disorder in adults between 30 and 50 years of age but can also occur in children.

When you have PPPD, your brain cannot properly interpret space and motion. This can be due to a variety of factors that create disruption within or between the systems that coordinate visual and postural control.

Functional medicine offers a holistic approach to understanding and treating PPPD. Functional medicine for PPPD treatment evaluates underlying factors contributing to symptoms and aims to support the brain in re-establishing a better sense of perception and balance. 

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Understanding PPPD: Symptoms and Conventional Treatments

Persistent Postural-Perceptual Dizziness (PPPD) causes long-lasting dizziness or a sense of floating in space or being off balance. It can make someone feel like they are swaying from side to side while standing still. People with PPPD may report that they feel like they are swaying as if on a boat or that they feel like they are about to fall over. Patients often report issues with walking and driving. 

A diagnosis of PPPD requires symptoms of unsteadiness, dizziness, or non-vertiginous dizziness that occur on most days for at least 90 days. This dizzy sensation lasts for hours (vs. seconds or minutes) and often becomes more intense in certain positions, including sitting upright, standing, or walking. Often, symptoms wax and wane but are persistent overall. It can also be triggered by visually complex stimuli like moving cars or being in a crowded environment.

Usually, people with PPD may have a mostly normal physical and neurological exam and imaging studies. They may display some swaying on a gait exam due to vestibular imbalance or disruption in compensatory mechanisms but do not usually fall over. 

PPPD is classified as a chronic vestibular disorder. PPPD is also associated with migraine, anxiety, and depression. It occurs more frequently in women than men, with a ratio as high as 4 to 1. 

In people with PPPD, the normal filters that help the brain suppress excess feelings of movement become disrupted. This makes it difficult to retain a sense of balance and stability. Instead, you may feel a sense of movement even when you should not. Understandably, this can create anxiety, fatigue, and trouble concentrating, especially in crowded environments or places with a lot of stimuli. 

Conventional treatment of PPPD is usually multimodal. It aims to help re-establish an improved sense of perception and balance within the brain and body. Common treatments include cognitive-behavioral therapy, physical vestibular therapy, and serotonergic medications like SSRIs and SNRIs. 

Identifying Potential Triggers and Underlying Causes

Although the etiology is still under study, PPPD can be triggered by conditions that impact balance, including metabolic issues, psychological distress, or a condition that impacts the nervous system and/or ears, such as vestibular neuritis, benign paroxysmal positional vertigo (BPPV), or Meniere’s disease. 

Often, PPPD first develops when dizziness persists after a migraine, mild head injury, or infection. Studies show that approximately 25% of people with vestibular disorders like BPPV, vestibular neuritis, and Meniere’s disease develop PPPD after the resolution of their vestibular dysfunction. In another 20% of cases, a vestibular migraine proceeds the development of the condition. Panic attacks, PTSD, or generalized anxiety are also common triggers, and autonomic disorders are less commonly identified as the underlying triggers. More rare triggers include heart dysrhythmias or adverse drug reactions. 

These impacts result in changes in how the body perceives itself in space and alter the balance between coordinating visual-somatosensory cues, environmental vigilance, and changes in posture. Research shows that central sensitization seems to impact dizziness and other symptoms of PPPD. Central sensitization is a neurophysiological condition that involves changes in the nervous system that result in stimuli causing more intense outputs than expected due to the hyperexcitability of the central nervous system. 

Studies are investigating ways in which visual and somatosensory dysfunction, anxiety, stress, chronic smoking, and fear may contribute to an over adaptation of equilibrium function that results in the dizziness experienced by people with PPPD. 

The Functional Medicine Perspective on PPPD

Balance disorders like PPPD can be difficult to diagnose and treat. Since PPPD often has no defining findings on physical examination or imaging, a functional medicine approach is especially useful. 

From a functional medicine perspective on PPPD, it is crucial to listen to the patient’s story and experience with her symptoms. Allowing the patient to fully describe and explain what her dizziness is like is a key part of determining possible causes that may be contributing to and triggering this vestibular issue. Taking a thorough patient history and functional medicine assessment is valuable for helping to uncover factors contributing to the onset of PPPD so that a personalized management plan can be developed.

A functional medicine approach also recognizes the many components of PPPD that someone can experience. A thorough assessment based on a complete understanding of this condition looks to identify all of the various component symptoms that can occur with PPPD. These can include fatigue, difficulty concentrating, neck pain, anxiety, depression, and nausea. Recognizing these various components of someone’s experience with PPPD allows each of these issues to be addressed as part of a personalized plan to improve functioning and quality of life. 

A holistic approach to dizziness disorders is also key for improving quality of life and safe functioning. A multidisciplinary team, including functional medicine providers, neurologists, otolaryngologists, psychiatrists when appropriate, and vestibular therapists, provides care for the whole person. 

Nutritional Interventions in PPPD Management

Dietary interventions for dizziness can help reduce symptoms and improve overall health. Keeping blood sugars and fluid balance stable can improve vestibular symptoms. 

In general, an anti-inflammatory diet that eliminates ultra-processed foods, added sugars, and artificial additives can improve dizziness. Focus on fresh vegetables, fruits, seeds, and other whole foods that you are not sensitive to or allergic to, and avoid highly processed sugars and simple carbohydrates on their own. Eat regular meals containing a balance of fats, proteins, and complex carbohydrates to avoid your blood sugar dropping too low and triggering a migraine or dizziness. 

It is also helpful to avoid foods that can trigger migraines and dizziness, like alcohol, MSG, nitrite and nitrate-preserved foods (like hot dogs and pepperoni), and foods that contain the amino acid tyramine such as red wine, smoked meats, sour cream, pickled herring, chocolate, bananas, citrus fruits, figs, ripened cheeses, and peanut butter.

Since the gut and brain are so intricately connected via the gut-brain axis, optimizing the health of your gut and the microbes that reside there is important for reducing anxiety and improving brain function in PPPD. The composition of the gut microbiome has been shown to influence a variety of neurologic and psychiatric disorders.

You can nourish your gut and keep your microbiome balanced by eating an anti-inflammatory, nutrient-dense, and probiotic-rich diet. Focusing on whole foods rich in prebiotics, fiber, phytonutrients, polyphenols, and natural probiotics in fermented foods, if tolerated, can support your gut microbiome, intestinal lining, and brain health.

Depending on individual factors, research suggests that certain supplements can be beneficial in improving symptoms of vestibular disorders like PPPD. Supplements like magnesium, feverfew, and riboflavin improve inflammation and help reduce symptoms like dizziness, vertigo, and anxiety. 

For example, migraines frequently trigger PPPD, so reducing their frequency can help reduce symptoms. 400-800 mg of magnesium in divided doses each day is recommended for migraine prevention. The frequency of migraines was lowered by 41.6% when the participants took 600 mg of magnesium citrate daily for 6 weeks in one study.

Feverfew has also been shown to reduce the frequency of migraines and other vestibular symptoms. This herb can reduce pain, light sensitivity, and migraine associated with migraine headaches with no serious side effects. Caution should be used in those sensitive to plants in the ragweed family.

Riboflavin, or vitamin B2, is also used to prevent migraine attacks. A dose of 400 mg a day was shown to be effective in significantly reducing headache frequency.

Stress Reduction and Mind-Body Techniques

Stress, anxiety, and depression are common in people with PPPD. These chronic issues can exacerbate, trigger, and result from dealing with dizziness. It can turn into a vicious cycle with stress and anxiety triggering dizziness and the discomfort of dizziness, adding more and more stress and anxiety. 

There is a physiologic basis for this connection. Elevated levels of stress hormones like cortisol can interfere with nerve signaling and communication between the vestibular system and the brain. In addition, chemical messengers like histamine can increase during stress and further impair neurotransmission and signaling that impacts the vestibular system. 

Dizziness in PPPD is commonly associated with psychiatric conditions, especially depression and anxiety. These symptoms are frequently exacerbated by poor sleep quality and chronic stress.

Mind-body techniques in dizziness management, like yoga, meditation, and tai chi, can help to reduce chronic stress, migraines, and vestibular dysfunction. Meaningful stress management practices like these help to shift your body into a parasympathetic state where stress hormones are reduced, and you can better manage anxiety. 

Physical and Vestibular Therapy Approaches

Vestibular and physical therapy for PPPD can be used to help relieve the dizziness and improve safer functioning. Physical therapy can be helpful in many ways. Vestibular balance rehabilitation therapy is used to train and integrate the movement of the eyes, head, and body movements to allow for better tolerance of moving stimuli. Other types of physical therapy and exercises can also be integrated into treatment to address the natural tendency for most people with PPPD to avoid moving their eyes, neck, and body as much as they used to in order to try to reduce discomfort and symptoms. 

This physical therapy approach helps to improve stability and a person’s confidence in staying balanced. Walking exercises, balance retraining, and visual and postural exercises are used to help retrain a patient’s vestibular system and reduce symptoms of PPPD. 

A customized program can be tailored to individual needs within a functional medicine framework. While traditionally, vestibular rehabilitation has been delivered by a therapist, emerging techniques are making it more accessible and available to fit within an individual’s life. Self‐directed video game‐ and internet‐based packages are now available that allow patients to complete exercises in their own homes. This is important in making these therapies more accessible since vestibular rehabilitation for PPPD requires repetitive exercises to cause habituation that leads to a reduction in the abnormal balance signals that are generated by routine stimuli in order to re‐establish normal balance function.

Vestibular therapy has been shown to help improve balance and allow people to return to their daily activities more safely. Therapy of this kind is helpful for teaching people how to better manage their unique triggers as well. This approach is a key part of a functional medicine framework that addresses each individual’s underlying triggers to help improve quality of life and function. 

Personalized Lifestyle Modifications

An important component of improving the quality of life for people with PPPD is empowering them with steps they can take to understand and cope with this disruptive condition. It is important to help patients understand their condition and teach them powerful ways that they can help manage their symptoms. 

Lifestyle modifications for PPPD empower patients to take steps in their daily life that can improve their symptoms. For example, movement techniques aimed at fatiguing abnormal reflexive responses to daily tasks can be practiced at home to help reduce enhanced sensitivity to visual stimuli. 

A personalized exercise or movement plan can be developed with a qualified physical or vestibular therapist to address each individual’s needs and symptoms. Exercises should be started gradually and increased slowly but steadily over time to avoid exacerbating symptoms. Safely practicing movements with the guidance of a professional can help patients to regain confidence and overcome the fear of dizziness and other symptoms. 

Avoiding triggers and adapting routines to keep symptoms more stable are important parts of personalized care in PPPD management. Since pain, trauma, or overuse of the neck can sometimes contribute to PPPD, ensuring an ergonomic workstation can be helpful in many cases. 

It is also important to consider sleeping posture and environment. A properly supportive pillow and mattress made of non-toxic materials can help improve sleep and neck stability. Establishing a sleep routine that helps you calmly transition into restorative rest is important for managing fatigue, stress, and anxiety that commonly accompanies this condition. Try to go to bed and wake up at the same time each day and keep your bedroom quiet, comfortably cool, and dark to help you get at least 7-10 hours of solid sleep each night. 

Integrating Conventional and Functional Approaches

A functional medicine approach to PPPD looks at the person as a whole. This helps to uncover factors contributing to symptoms like dizziness and unsteadiness. In this way, a comprehensive treatment plan can be developed and personalized for an individual patient’s needs.

PPPD is most successfully treated using a collaborative and multi-modal approach involving various healthcare professionals working together. For example, psychological and/or psychiatric care providing effective treatments for accompanying anxiety, depression, and stress has been shown to enhance quality of life and functioning. This may involve cognitive behavioral therapy (CBT), which has successfully been used as an adjuvant treatment to enhance the success of vestibular rehabilitation. In this setting, CBT is often used to teach patients how to re-focus on meaningful and productive activities to be able to function more fully, even when some symptoms of dizziness and anxiety persist.

Antidepressant medications, which include selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors, are also commonly used in treating PPPD, with benefits that are not limited to patients with co-morbid depression, anxiety, or other psychiatric illnesses. 

Another emerging treatment approach that is integrated into a multi-modal plan to manage the symptoms of PPPD is virtual reality therapy. Research suggests that adding virtual reality therapy to a customized vestibular rehabilitation program significantly reduces PPPD symptoms. 

​​Transcranial direct current stimulation is another technique that is being studied for managing PPPD. This therapy uses electrodes placed onto the scalp to provide a weak current of electrical stimulation of the brain.

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Persistent Postural-Perceptual Dizziness (PPPD): Key Takeaways

PPPD occurs when there is a mismatch between visual and vestibular input and how the brain processes and interprets this information. It can cause significant difficulty in functioning and quality of life since it makes people feel unsteady and off balance. Due to this unsettling feeling, it is often associated with marked anxiety, depression, and stress.

A functional medicine approach to managing PPPD emphasizes truly listening to the patient to understand what her individual experience with the condition entails. This allows for a thoughtful uncovering of contributing factors to the dizziness. These can then be targeted with lifestyle, nutrition, stress management, and vestibular therapy approaches. 

A multi-faceted treatment approach for PPPD treats vestibular, psychiatric, lifestyle, and other factors. This functional medicine approach emphasizes treating the whole person and not just her symptoms to more effectively improve both function and quality of life.