What is the best management approach for Disembarkment syndrome (mal de débarquement)?

Management of Mal de Débarquement Syndrome (MdDS)

The most effective management approach for Mal de Débarquement Syndrome is treatment with benzodiazepines and/or antidepressants, which have been reported as most beneficial in reducing symptoms according to patient reports. 1

Understanding MdDS

Mal de Débarquement Syndrome is a neurological disorder affecting the vestibular system, characterized by:

• Persistent sensation of rocking, bobbing, or swaying
• Symptoms typically begin after exposure to passive motion (e.g., boat or plane ride)
• Can also occur spontaneously without prior motion exposure
• Symptoms temporarily improve during passive motion (e.g., driving in a car)
• Associated with chronic fatigue, anxiety, and depression

Diagnostic Approach

MdDS is primarily a diagnosis of exclusion:

• Normal inner-ear function tests
• Normal brain imaging
• Negative or non-specific clinical findings
• Thorough clinical history revealing persistent motion sensation after disembarkation

Treatment Algorithm

First-Line Treatment:

1. Pharmacological Management

   • Benzodiazepines (most helpful according to patient reports) 1
   • Antidepressants (particularly nortriptyline) 1, 2
   • Migraine prophylaxis medications:
     • Verapamil
     • Topiramate
     • Combination therapy as needed 2

2. Migraine Management Protocol

   • 73% of MdDS patients responded well to management with vestibular migraine protocols 2
   • Particularly effective for patients with personal or family history of migraines

Second-Line Approaches:

1. Stress Reduction Strategies

   • Stress management techniques (likely effective due to their stress-reducing capacities) 1
   • Relaxation techniques

2. Lifestyle Modifications

   • Similar to those used for vestibular migraine management 2
   • Adequate sleep hygiene
   • Regular physical activity (non-vestibular challenging)
   • Avoidance of known triggers

Limited Efficacy Approaches:

1. Vestibular Rehabilitation

   • Traditional vestibular rehabilitation has questionable efficacy for MdDS 3
   • May reduce sway velocity but doesn't modify frequency content of postural sway
   • Does not significantly improve Dizziness Handicap Inventory scores in MdDS patients

2. Emerging Treatments

   • Optokinetic stimulation
   • Transcranial magnetic stimulation 4
   • These approaches show promise but require further research

Important Considerations

• Prognosis: Symptoms typically dissipate over several hours or days but can persist for weeks or become chronic 5
• Reassurance: For acute cases, patients can be reassured that symptoms are typically transient 5
• No Workup Required: For typical post-travel cases with characteristic symptoms, extensive testing is unnecessary 5
• Mental Health Support: Address associated anxiety and depression, which can significantly impact quality of life 4

Pitfalls to Avoid

1. Diagnostic Delays: MdDS is often unrecognized, leading to multiple physician visits and unnecessary diagnostic testing 4
2. Inappropriate Treatments: Avoid treatments focused solely on peripheral vestibular rehabilitation, as they show limited efficacy 3
3. Overlooking Migraine Connection: Many MdDS patients have personal or family history of migraines and respond to migraine protocols 2
4. Neglecting Psychological Impact: Failure to address anxiety and depression can worsen quality of life 4
5. Excessive Testing: For typical presentations, extensive vestibular testing may be unnecessary and increase patient stress 5

By following this management approach, clinicians can provide more targeted and effective care for patients with this challenging and often misunderstood condition.