What is the treatment for Mal de barquement syndrome?

Treatment of Mal de Débarquement Syndrome

The most effective treatment approach for Mal de Débarquement Syndrome (MdDS) includes vestibular rehabilitation therapy combined with benzodiazepines or antidepressants for symptom management, with vestibulo-ocular reflex (VOR) readaptation therapy showing a 64% success rate in recent studies. 1

Understanding Mal de Débarquement Syndrome

Mal de Débarquement Syndrome is a neurological disorder characterized by a persistent sensation of motion (rocking, swaying, or bobbing) that typically occurs after exposure to passive motion, such as boat travel, flights, or car rides. Unlike motion sickness, MdDS symptoms begin after the motion has ceased and can persist for extended periods, significantly impacting quality of life. 2

MdDS can be classified into two main types:

• Motion-Triggered MdDS (MT-MdDS): Occurs after exposure to passive motion (e.g., cruise, flight)
• Spontaneous/Other Onset MdDS (SO-MdDS): Occurs without clear motion exposure

Treatment Approaches

1. Vestibulo-Ocular Reflex (VOR) Readaptation Therapy

This is currently the most evidence-supported specific treatment for MdDS:

• Protocol: Optokinetic stimulation paired with head roll at 0.167 Hz over 2-5 consecutive days
• Session structure: Four-minute treatment blocks twice in morning and afternoon
• Success rate: 64.1% overall (64.2% for MT-MdDS and 63.3% for SO-MdDS) 1
• Factors affecting success: Treatment is generally more effective when initiated early after symptom onset and in younger patients 3

2. Pharmacological Management

Medications that have shown benefit in MdDS patients:

• Benzodiazepines: Reported as most beneficial for symptom reduction in patient surveys 4

  • Examples: Clonazepam, diazepam
  • Mechanism: Likely reduces vestibular symptoms through GABA-mediated inhibition

• Antidepressants: Also reported as beneficial by patients 4

  • Examples: Nortriptyline, SSRIs
  • Mechanism: May modulate central processing of vestibular signals

3. Vestibular Migraine Protocol

Given the overlap between MdDS and migraine, treating MdDS as vestibular migraine has shown promise:

• Success rate: 73% of patients responded well to this approach 5
• Protocol includes:
  • Lifestyle modifications
  • Pharmacotherapy with:
    • Verapamil
    • Nortriptyline
    • Topiramate
    • Or combinations thereof

4. Lifestyle and Dietary Modifications

• Small, frequent meals to prevent fluctuations in blood glucose
• Avoidance of triggers that worsen symptoms
• Stress reduction techniques (meditation, deep breathing)
• Regular sleep schedule
• Moderate exercise as tolerated

Treatment Algorithm

1. Initial Assessment:

   • Confirm diagnosis (persistent motion sensation after travel or spontaneous onset)
   • Rule out other vestibular disorders
   • Assess severity using visual analog scale

2. First-line Treatment:

   • Refer for VOR readaptation therapy if available
   • Start benzodiazepines (e.g., clonazepam 0.5mg daily) or antidepressants (e.g., nortriptyline 10-25mg daily)
   • Implement stress reduction techniques

3. If inadequate response after 4-6 weeks:

   • Consider vestibular migraine protocol (especially if personal/family history of migraine)
   • Trial of verapamil, topiramate, or combination therapy

4. For refractory cases:

   • Consider referral to specialized centers offering advanced VOR readaptation
   • Evaluate for comorbid conditions (anxiety, depression) that may require specific management

Important Considerations

• Early treatment is key: Success rates are inversely correlated with symptom duration 3
• Avoid symptom triggers: Patients should be cautious with activities that may exacerbate symptoms
• Travel precautions: Prolonged travel (especially by air or car) may contribute to symptomatic reversion after successful treatment 3
• Psychological support: Many patients benefit from counseling to manage the chronic nature of symptoms

Common Pitfalls to Avoid

• Delayed diagnosis: MdDS is often misdiagnosed as anxiety or psychogenic dizziness
• Inadequate treatment duration: Pharmacological treatments may require several weeks to show benefit
• Overlooking migraine connection: Failure to recognize and treat underlying migraine physiology
• Lack of follow-up: Patients require ongoing monitoring and adjustment of treatment plans

The treatment of MdDS remains challenging, but a structured approach focusing on VOR readaptation, appropriate medication, and lifestyle modifications offers the best chance for symptom improvement and enhanced quality of life.