Can vortioxetine (Brintellix) help with vestibular migraines and dysbarment (also known as mal de débarquement) syndrome?

Vortioxetine for Vestibular Migraines and Mal de Débarquement Syndrome

Vortioxetine may be beneficial for treating mal de débarquement syndrome (MdDS) when approached as a vestibular migraine variant, due to its multimodal serotonergic mechanism that addresses both depression and cognitive symptoms that often accompany these disorders.

Understanding the Connection Between Vestibular Migraines and MdDS

Mal de débarquement syndrome (MdDS) is characterized by a persistent sensation of rocking or swaying, typically occurring after exposure to passive motion such as boat or plane travel. Recent evidence suggests a strong connection between MdDS and vestibular migraines:

• MdDS predominantly affects middle-aged women (mean age 49-50 years) 1, 2
• Patients with MdDS and comorbid vestibular migraine (MDDS-VM) experience:
  • Earlier age of onset (41 vs. 52 years)
  • More severe symptoms
  • Greater disability
  • More interictal symptoms
  • Higher Dizziness Handicap Inventory scores
  • Greater job impact 2

Mechanism of Action of Vortioxetine

Vortioxetine's potential benefit in these conditions stems from its unique pharmacological profile:

• Multimodal serotonergic activity:
  • 5-HT reuptake inhibition
  • 5-HT1A receptor agonism
  • 5-HT1B receptor partial agonism
  • 5-HT3, 5-HT1D, and 5-HT7 receptor antagonism 3

These mechanisms may address both the vestibular symptoms and associated cognitive/mood symptoms that often accompany MdDS.

Evidence for Serotonergic Medications in Vestibular Disorders

While no guidelines specifically recommend vortioxetine for MdDS or vestibular migraines, there is evidence supporting serotonergic medications:

1. The American College of Cardiology/American Heart Association guidelines state: "In patients with recurrent VVS (vasovagal syncope), a selective serotonin reuptake inhibitor might be considered" 4

2. Research specifically on MdDS management shows:

   • 73% of MdDS patients responded well to management with a vestibular migraine protocol, which included medications like nortriptyline (a tricyclic antidepressant with serotonergic effects) 5
   • Venlafaxine (an SNRI) was the most commonly used effective treatment (27.3%) across all MdDS patient groups 2

Treatment Approach for MdDS as Vestibular Migraine

Based on the available evidence, a treatment algorithm for MdDS with vestibular migraine features would include:

1. First-line pharmacotherapy options:

   • Venlafaxine (most commonly reported effective treatment) 2
   • Vortioxetine (potential benefit due to multimodal serotonergic action) 3
   • Nortriptyline (shown effective in vestibular migraine protocol) 5

2. Additional therapeutic options:

   • Antiepileptic drugs (e.g., topiramate)
   • Migraine preventive vitamins 2
   • Benzodiazepines (reported to provide some benefit) 1

Important Considerations and Caveats

• Traditional vestibular suppressants like meclizine and scopolamine are generally ineffective for MdDS 1
• Vestibular rehabilitation therapy alone provides only minimal benefit for most MdDS patients 1
• The condition is often refractory to standard treatments, highlighting the need for targeted approaches like serotonergic medications

Why Vortioxetine May Be Particularly Beneficial

Vortioxetine offers several advantages over other serotonergic medications for MdDS patients:

1. Improved cognitive function alongside mood effects 3
2. Better tolerability profile than many other antidepressants 3
3. Potential analgesic and anti-inflammatory properties that may address comorbid symptoms 3
4. Dose-dependent effects allowing for personalized titration 3

Given the significant impact of MdDS on quality of life 6 and the emerging understanding of its relationship with vestibular migraine, vortioxetine represents a promising therapeutic option that addresses both the primary vestibular symptoms and common comorbidities.