High beta activity tracks disease state in persistent postural-perceptual dizziness: A longitudinal quantitative EEG study

Background Persistent postural-perceptual dizziness (PPPD) is a chronic vestibular disorder lacking objective tools for monitoring disease activity. Quantitative electroencephalography (qEEG) has identified cortical hyperexcitability in migraine, but whether analogous patterns exist in PPPD and reverse with treatment is unknown. We investigated high beta (25–30 Hz) activity as a state-dependent biomarker for PPPD. Methods This retrospective longitudinal study analyzed 19-channel resting-state qEEG from 163 unmedicated PPPD patients, 86 healthy controls (HC), and 67 vestibular migraine (VM) patients as a dizzy control group at a specialized neurology clinic. Absolute power was z-score normalized against an age-adjusted reference database. The primary outcome was the number of electrodes with high beta absolute power z-score > +1.96; the continuous mean high beta z-score served as a confirmatory outcome. Patients were followed through pharmacotherapy, with qEEG repeated at follow-up ( n = 107) and at relapse after discontinuation ( n = 23). Results High beta electrode counts were graded across groups and highest in PPPD (median: HC 2 [IQR 0–4], VM 7 [3–13], PPPD 16 [12–18]; all pairwise p < 0.001), discriminating PPPD from HC with an AUC of 0.956 (OR = 1.53 per electrode; 95% CI 1.38–1.69); the continuous mean z-score yielded a comparable AUC (0.948). Within PPPD, high beta count was not confounded by age, sex, comorbid migraine, or anxiety (all p > 0.30). Marked responders (n = 76) showed near-normalization of high beta electrode count (17 → 2.5; Cohen’s d = 2.58), whereas partial responders ( n = 31) showed smaller reductions (15 → 11; p < 0.001). Clinical improvement correlated with reduction in high beta electrode count (ρ = 0.509; p < 0.001). Relapse after discontinuation produced a V-shaped trajectory ( n = 23; 15 → 2 → 13). Conclusions On qEEG, high beta—trans-diagnostic but most pronounced in PPPD—represents a promising state-dependent biomarker. Its cross-sectional elevation versus controls establishes it as a valid marker, while its differential reduction with treatment and V-shaped relapse trajectory support its potential as a clinically accessible metric for within-subject monitoring of disease activity in PPPD. These findings warrant multicenter, prospective validation.