Is Trintellix (vortioxetine) effective in treating Mal de Debarquement syndrome?

Trintellix (Vortioxetine) for Mal de Debarquement Syndrome

There is no evidence supporting the use of Trintellix (vortioxetine) specifically for Mal de Debarquement Syndrome (MdDS), and treatment should instead focus on established approaches including vestibular migraine protocols, benzodiazepines, or specialized vestibulo-ocular reflex readaptation therapy.

Understanding Mal de Debarquement Syndrome

Mal de Debarquement Syndrome (MdDS) is a rare neurological disorder characterized by persistent sensations of rocking, swaying, or bobbing, typically occurring after exposure to passive motion such as boat or plane travel. Key features include:

• Predominantly affects middle-aged women (approximately 80% of cases) 1
• Symptoms typically persist for a month or longer
• Unlike other vestibular disorders, symptoms often improve with re-exposure to motion
• Higher prevalence of migraine in MdDS patients compared to the general population

Evidence-Based Treatment Approaches for MdDS

1. Vestibular Migraine Protocol

The strongest evidence for MdDS treatment comes from a prospective study showing significant improvement when treating MdDS as vestibular migraine:

• 73% of patients responded well to a vestibular migraine management protocol 2
• Treatment included lifestyle modifications and pharmacotherapy with:
  • Verapamil
  • Nortriptyline
  • Topiramate
  • Or combinations thereof

This approach was superior to traditional vestibular rehabilitation therapy alone, which showed limited efficacy in a retrospective control group 2.

2. Benzodiazepines

• May provide symptomatic relief in some patients 1
• Limitations include potential for dependence and addiction
• Common vestibular suppressants are generally ineffective for MdDS 1

3. Specialized Vestibulo-Ocular Reflex (VOR) Readaptation

A recent standardized protocol has shown promising results:

• 64.1% overall success rate in a study of 131 patients 3
• Treatment involves optokinetic stimulation paired with head roll movements
• Effective for both motion-triggered and spontaneous-onset MdDS
• Administered over 2-5 consecutive days with multiple treatment blocks daily

4. Transcranial Magnetic Stimulation (TMS)

Emerging evidence suggests potential benefit:

• A pilot study using a novel rTMS paradigm showed symptom reduction in 50% of patients 4
• Protocol involved 1 Hz stimulation over ipsilateral DLPFC followed by 10 Hz stimulation over contralateral DLPFC
• Significant improvements were observed in 3 out of 10 subjects

Why Not Trintellix (Vortioxetine)?

While Trintellix is an effective antidepressant for major depressive disorder 5, there are several reasons it may not be appropriate for MdDS:

1. No clinical studies have evaluated Trintellix specifically for MdDS
2. Other antidepressants with established efficacy in similar conditions (like nortriptyline) have already demonstrated benefit in MdDS 2
3. SNRIs like duloxetine have established efficacy for neuropathic pain 5, but this mechanism may not address the underlying pathophysiology of MdDS

Treatment Algorithm for MdDS

1. First-line approach: Vestibular migraine protocol

   • Lifestyle modifications (trigger avoidance, sleep hygiene)
   • Consider nortriptyline, verapamil, or topiramate based on comorbidities
   • Monitor for at least 4-6 weeks for response

2. Second-line approach: VOR readaptation therapy

   • Consider referral to specialized centers offering this treatment
   • Protocol involves optokinetic stimulation with head roll movements
   • Typically administered over 2-5 consecutive days

3. Third-line approaches:

   • Benzodiazepines (with caution regarding dependency)
   • Consider rTMS if available at specialized centers
   • Traditional vestibular rehabilitation has questionable efficacy 6

Important Considerations and Pitfalls

• Misdiagnosis: Ensure MdDS is properly distinguished from other vestibular disorders
• Medication overuse: Avoid prolonged use of vestibular suppressants which show limited efficacy
• Comorbid conditions: Address concurrent anxiety, depression, and sleep disorders which may exacerbate symptoms
• Patient expectations: Set realistic goals as complete symptom resolution may not be achievable in all cases
• Benzodiazepine dependence: Use caution with long-term benzodiazepine therapy due to addiction potential 1

Conclusion

When treating patients with MdDS, the evidence most strongly supports a vestibular migraine protocol or specialized VOR readaptation therapy. There is currently no evidence supporting the use of Trintellix specifically for this condition.