What are the benefits and risks of different medications used to treat persistent postural-perceptual dizziness (PPPD)?

Key messages

We did not identify any studies that assessed the use of medication to treat persistent postural-perceptual dizziness (PPPD). 

Further work is needed in this area to help establish whether there are any treatments that may be effective at treating this condition, and to check if they cause any unwanted or harmful effects. 

What is PPPD?

PPPD stands for persistent postural-perceptual dizziness. People with this condition have symptoms of dizziness or unsteadiness, which are worse when standing up or moving around, or with rich visual stimulation (from complicated patterns or busy moving images). 

How is PPPD treated?

Sometimes people may take medication to try and help their symptoms of PPPD. This includes medicines known as 'selective serotonin reuptake inhibitors' (SSRIs) and 'serotonin and norepinephrine reuptake inhibitors' (SNRIs). Other treatments may also be used, for example a type of physiotherapy known as vestibular rehabilitation, or talking therapies. 

What did we want to find out?

We wanted to find out:

- whether there was evidence that medication (SSRIs and SNRIs) helps to improve the symptoms of PPPD;

- whether these treatments might cause any harm.

What did we do?

We searched for studies that compared SSRIs and SNRIs to either no treatment or placebo (dummy) treatment. 

What did we find?

We did not find any studies that assessed the use of these medicines for PPPD. Therefore, we do not know if SSRIs and SNRIs are effective for the treatment of PPPD, or whether they might cause any harm. 

What are the limitations of the evidence?

Further research is needed to identify whether these medications are useful for the treatment of PPPD. 

How up-to-date is this evidence?

The evidence is up-to-date to November 2022. 

Authors' conclusions: 

At present, there is no evidence from placebo-controlled randomised trials regarding pharmacological treatments - specifically SSRIs and SNRIs - for PPPD. Consequently, there is great uncertainty over the use of these treatments for this condition. Further work is needed to establish whether any treatments are effective at improving the symptoms of PPPD, and whether their use is associated with any adverse effects. 

Read the full abstract...

Persistent postural-perceptual dizziness (PPPD) is a chronic balance disorder, which is characterised by subjective unsteadiness or dizziness that is worse on standing and with visual stimulation. The condition was only recently defined and therefore the prevalence is currently unknown. However, it is likely to include a considerable number of people with chronic balance problems. The symptoms can be debilitating and have a profound impact on quality of life. At present, little is known about the optimal way to treat this condition. A variety of medications may be used, as well as other treatments, such as vestibular rehabilitation. 


To evaluate the benefits and harms of pharmacological interventions for persistent postural-perceptual dizziness (PPPD). 

Search strategy: 

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 21 November 2022.

Selection criteria: 

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with PPPD, which compared selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) with either placebo or no treatment. We excluded studies that did not use the Bárány Society criteria to diagnose PPPD and studies that followed up participants for less than three months. 

Data collection and analysis: 

We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vestibular symptoms (assessed as a dichotomous outcome - improved or not improved), 2) change in vestibular symptoms (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) generic health-related quality of life and 6) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We planned to use GRADE to assess the certainty of evidence for each outcome. 

Main results: 

We identified no studies that met our inclusion criteria.

Health topics: