What is the treatment approach for Mal de Débarquement Syndrome (MdDS)?

Treatment Approach for Mal de Débarquement Syndrome (MdDS)

The most effective treatment for Mal de Débarquement Syndrome (MdDS) is vestibular-ocular reflex (VOR) readaptation therapy using optokinetic stimulation with head roll, which has shown a 64% success rate in reducing symptoms regardless of whether the condition was motion-triggered or spontaneous in onset. 1

Understanding MdDS

MdDS is a rare vestibular disorder characterized by:

• Persistent sensation of rocking, swaying, or bobbing
• Symptoms that typically begin after passive motion exposure (e.g., boat or plane travel)
• Can also occur spontaneously without prior motion exposure
• Predominantly affects women
• Symptoms can persist for months or years without treatment

Treatment Options

First-Line Treatment: VOR Readaptation Therapy

This specialized treatment involves:

• Optokinetic stimulation paired with rhythmic head rolling at 0.167 Hz
• Treatment sessions typically conducted over 2-5 consecutive days
• Four-minute treatment blocks scheduled twice in the morning and afternoon
• Shown to provide significant improvement in 64.1% of patients 1

Implementation details:

• Patient views a full-field, omni-directional optokinetic stimulus
• Patient rolls head rhythmically for up to 4 minutes per session
• Treatment can be administered in audiology-vestibular clinics with proper equipment 2

Second-Line Treatment: Management as Vestibular Migraine

For patients who don't respond to VOR readaptation or don't have access to it:

• Treatment with migraine prophylaxis medications has shown benefit in 73% of MdDS patients 3
• Medication options include:
  • Verapamil
  • Nortriptyline
  • Topiramate
  • Combination therapy

Supportive Treatments

• Benzodiazepines for short-term symptom relief (not for long-term use)
• Lifestyle modifications to reduce triggers
• Mental health support for associated anxiety/depression

Treatment Algorithm

1. Early intervention is critical - Treatment success is inversely correlated with symptom duration 4

2. Initial treatment: VOR readaptation therapy

   • If available, this should be the first treatment attempted
   • 4-5 days of treatment with multiple sessions per day
   • Objective assessment with posturography before and after treatment

3. If VOR readaptation is unavailable or unsuccessful:

   • Trial of vestibular migraine protocol including:
     • Lifestyle modifications
     • Pharmacotherapy with verapamil, nortriptyline, or topiramate

4. For persistent symptoms:

   • Consider combination therapy
   • Address psychological impacts with appropriate mental health support

Important Considerations

• Avoid prolonged travel immediately after treatment as this may contribute to symptom recurrence 4
• Traditional vestibular rehabilitation alone has questionable efficacy for MdDS 5
• Early diagnosis and treatment significantly improve outcomes 4
• Complete remission occurs in approximately 27% of motion-triggered and 19% of spontaneous MdDS patients after treatment 4

Prognosis

• Without treatment, symptoms persisting beyond 6 months have historically been unlikely to remit
• With VOR readaptation treatment:
  • Initial improvement rate: 78% for motion-triggered MdDS, 48% for spontaneous MdDS
  • One-year sustained improvement: 52% for motion-triggered, 48% for spontaneous MdDS 4
  • Complete remission at one year: 27% for motion-triggered, 19% for spontaneous MdDS 4

The treatment of MdDS requires specialized approaches different from traditional vestibular rehabilitation. The standardized VOR readaptation protocol represents the most promising treatment option currently available, with significant potential to improve quality of life for these previously difficult-to-treat patients.