Primary or secondary chronic functional dizziness: does it make a difference? A DizzyReg study in 356 patients

Abstract

In 2017, the term "persistent postural-perceptual dizziness" (PPPD) was coined by the Bárány Society, which provided explicit criteria for diagnosis of functional vertigo and dizziness disorders. PPPD can originate secondarily after an organic disorder (s-PPPD) or primarily on its own, in the absence of somatic triggers (p-PPPD). The aim of this database-driven study in 356 patients from a tertiary vertigo center was to describe typical demographic and clinical features in p-PPPD and s-PPPD patients. Patients underwent detailed vestibular testing with neurological and neuro-orthoptic examinations, video-oculography during water caloric stimulation, video head-impulse test, assessment of the subjective visual vertical, and static posturography. All patients answered standardized questionnaires (Dizziness Handicap Inventory, DHI; Vestibular Activities and Participation, VAP; and Euro-Qol-5D-3L). One hundred and ninety-five patients (55%) were categorized as p-PPPD and 162 (45%) as s-PPPD, with female gender slightly predominating (♀:♂ = 56%:44%), particularly in the s-PPPD subgroup (64%). The most common somatic triggers for s-PPPD were benign paroxysmal positional vertigo (27%), and vestibular migraine (24%). Overall, p-PPPD patients were younger than s-PPPD patients (44 vs. 48 years) and showed a bimodal age distribution with an additional early peak in young adults (about 30 years of age) beside a common peak at the age of 50-55. The most sensitive diagnostic tool was posturography, revealing a phobic sway pattern in 50% of cases. s-PPPD patients showed higher handicap and functional impairment in DHI (47 vs. 42) and VAP (9.7 vs. 8.9). There was no difference between both groups in EQ-5D-3L. In p-PPPD, anxiety (20% vs. 10%) and depressive disorders (25% vs. 9%) were more frequent. This retrospective study in a large cohort showed relevant differences between p- and s-PPPD patients in terms of demographic and clinical features, thereby underlining the need for careful syndrome subdivision for further prospective studies.

Keywords: Age; Dizziness handicap inventory; Epidemiology; Functional dizziness; Gender; Quality of life; Vestibular syndromes.

Fig. 1

Somatic triggers for secondary functional dizziness. Pie chart of somatic triggers for secondary PPPD (n = 162) reported as relative percentages. Benign paroxysmal positional vertigo (BPPV), vestibular migraine, and acute unilateral vestibulopathy were the most common preceding organic diseases. Examples of relatively rare other organic triggers were mal de debarquement syndrome, vestibular paroxysmia, or superior canal dehiscence syndrome. TIA transient ischemic attack

Fig. 2

Age distribution density curve in primary and secondary PPPD. Primary (blue) and secondary PPPD (green) show a common peak at 50–55 years of age, whereas p-PPPD shows an additional peak in in young adults between 25 and around 30 years of age

Fig. 3

Boxplots of handicap, functioning, and participation in primary and secondary PPPD. The a Dizziness Handicap Inventory (DHI) total score and subscores (emotional, functional, physical), as well as b Vestibular Activities and Participation (VAP) subscales (1 = functioning and 2 = participation) in primary and secondary PPPD, both showing significantly higher impairment in s-PPPD than in p-PPPD in terms of the DHI total score (*p = 0.014), the DHI physical (⁺p < 0.001) and functional subscores (p = 0.008), as well as the VAP subscale 1 (*p = 0.038). n.s. not significant. Whiskers indicate 95% confidence intervals